Refer to Mayo Clinic through Online Services for Referring Physicians
and you’ll have the same access to lab results, radiology reports,
summary letters, hospital discharges and other patient records that
we do. Our secure, HIPAA-compliant, 24/7 Online Services for
Referring Physicians is just one of the ways we partner with you for
superior patient care. To learn more, call (904) 953-2517 or visit us
online at www.mayoclinic.org/medicalprofs.

From the Editor’s Desk
From the President’s Desk
Residents' Corner
Trends in Public Health
DCMS History Book
Northeast Florida Medicine Vol. 62, No. 3 2011 3

From the Editor’s Desk

Medicine: A Noble Profession in an Ever Challenging World
Written in memory and honor of my father, Salah Assar, MD, 1928 – 2011
In thinking about this editorial, I began to remember how I set my sights on medicine as a career and went for it. I made
a choice, a life changing one at that, to go through the grueling process of becoming a physician. It turned out to be one of
the biggest battles of my life. No matter what level of intelligence I possessed, I still needed an immense amount of discipline,
determination, and willingness to put in countless hours of hard work. I had to take it one day at a time. It was the only way to
accomplish such an overwhelming task. Failure was not an option.
I have asked colleagues why they went into medicine. I found that following a role model was
a relatively common factor in the decision to go into the profession. My role model was, and will
always remain my father, Dr. Salah Assar. As a Gastroenterologist, he handled his position in the
community with pride and responsibility. He made his work top priority.
My father considered his position an honor. He was enthusiastic, energetic, and caring. His
amazing work ethics and commitment to doing his best for his patients left people around him
in awe. Helping patients was a joy for him and it showed. As a result, I was proud and wanted
to be like him.

Raed Assar, MD, MBA
Editor-in-Chief
Northeast Florida Medicine

However, the bar seemed to be set too high. Growing up in the shadow of such an intellectual
giant left me with large shoes to fill. Any problem I had seemed trivial in comparison to the daily
issues he faced as he cared for his patients. I found myself asking, “Is my current question or
situation important enough to take my father away from his work?” The answer was frequently
“no”. This is something I have to keep in mind with my own family. Am I approachable when
they want to come to me for an answer or advice?

We listen to our patients and consider their thanks and praise the highest form of achievement,
and we thrive on such appreciation because for us, medicine is not simply a profession—it is a calling.
Sometime during our training or later on when we started practicing, reality set in—the world is not a perfect one. We faced
a medley of challenges in our careers and family lives. We spent less time celebrating our accomplishments and started taking
them for granted. Solving our patients’ or our own problems became our main focus. We took our work to bed whether in
sickness or in health. We started dealing with issues of control and found that disheartening place: the limits of our abilities. At
times our world was riddled with frustration and despair.
At these times, I found it necessary to stop and ask: Do I express appreciation to my loved ones for their support? I would be
remiss if I didn’t acknowledge how my wife and mother’s enduring love and care keep me going. Can we do what our patients
and society expect of us without such care? The answer is “no”. The goal then is to find balance in life and in thought.
So needless to say, before I accepted the appointment as the new Northeast Florida Medicine Editor-in-Chief, I considered how
this new responsibility would affect my balance of life and schedule. Additionally, I know my father would be proud to hear I
stepped forward into this role.
I would like to thank the DCMS President Dr. Malcolm Foster, Jr. and DCMS Executive Vice President Jay Millson for this
opportunity to serve. I will take on this new responsibility with the same pride and dedication that all of us gave to becoming
physicians. I promise to be objective, impartial, and above all balanced just like my predecessors.
This is an honor, and I will treat it as such. Please do not hesitate to share your opinions and suggestions. Thank you for your
support!

Welcome, Dr. Assar, as the new Northeast Florida Medicine Editor-in-Chief!

4 Vol. 62, No. 3 2011 Northeast Florida Medicine

www . DCMS online . org

From the President’s Desk

Preventive Medicine, Health Care Rationing
and DCMS Involvement: They Are Related
In the past I have written on the topic of promoting preventive medicine to achieve saving precious health care dollars. Each
time I approach this subject, I stay away from focusing on rationing. That word and the discussions it triggers are very emotional
and explosive. Yet, talking about rationing care is increasingly necessary in these days of soaring medical costs since many still
avoid following healthy lifestyles.
Some attainable solutions to high health care costs are reducing unnecessary and redundant tests,
not scheduling unnecessary surgeries, shortening hospitalizations and minimizing consultation
time; in a word, “rationing” health care.
Yes, health care dollars can also be saved by reducing the cost of drugs and durable medical
equipment. But it can be hard to restrict those prices when pharmaceutical and medical equipment
companies are for-profit entities always analyzing their bottom lines. As physicians, we have more
control over our patients’ repeat admissions to the hospital, often referred to as “bounce backs”.
If there were better patient compliance, another trip to the hospital might not be needed. Home
health and rehabilitation are expensive, but not as costly as inpatient care.

Malcolm T. Foster, Jr., MD
2011 DCMS President

The more complicated ethical questions surrounding “rationing” are: At what age should we
withhold dialysis? Should coronary bypass surgery be done on someone over 90 years of age? Are
any life sustaining therapies just too expensive for the elderly or chronically ill person? Should
those over 65 years of age, retired, and considered unproductive by society receive less and less care?

Right now, Medicare pays for these big ticket procedures, but this “Golden Goose” may stop
laying those valuable eggs and want hospitals and other health care organizations to be more responsible for poor outcomes,
unnecessary readmissions, and certain hospital acquired infections. I am worried that this debate will become so heated that
payers will arbitrarily deny care to avoid conflict. But I have to believe all is not lost if we promote good health to our patients,
speak in favor of more tort reform, and support quality standards in our profession.
Yet, can physicians influence the decisions that have been and will be made about who gets paid what for which procedures?
Our voices can and will be heard as we advocate loud and clear through organized medicine, subspecialty societies and involved
citizen groups.
Physician colleagues, where are you plugged in? Are you a member and active participant of any of these advocacy organizations? If you are reading this article, you are probably a Duval County Medical Society member. I trust you are not just a member
so DCMS can be listed on your CV. We need your real involvement which means attending meetings, serving as a committee
member, and getting connected with political action projects.

The 2011 DCMS Annual Meeting is scheduled for December 1, 2011 at the Hyatt Regency Jacksonville Riverfront. Why not
plan to be there? Clear your schedule for that evening from 5:45-9:00 p.m. and come to view the Exhibit Hall, connect with
other physicians, enjoy a good meal, see colleagues receive awards and witness the historic installation of only the third woman
DCMS President when Dr. Ashley Booth Norse is sworn in as the 125th President of the Duval County Medical Society. (The
first woman president was Dr. Kay Gilmour in 1992 and the second was Dr. Kay Mitchell in 2002.)
Will attending the Annual Meeting solve all the health care cost issues and settle the debate about rationing care? No, but it
is a step in the direction of connecting with your physician colleagues and showing support for your professional organization
that advocates for you, for medicine and for your patients in the local, state and national arenas. See you December 1!

At Brooks Rehabilitation, our comprehensive
approach to treatment extends beyond the
physical to include the psychological, social,
and cognitive aspects of recovery.
We are committed to helping the entire person,
which is why Brooks Behavioral Medicine
(BBM) is available. These specialized services
are available in our outpatient center by a
variety of highly trained professionals.

Physician Involvement Key in Curbing Health Care Costs
Cecil B. Wilson, MD - Immediate Past-President American Medical Association
Editor's Note: Philip H. Gilbert served as the Executive Vice President of the Duval County Medical Society (DCMS) from 1984 until
his unexpected death in 2004. During those decades, he was an outspoken advocate for the physicians he served and for the needs of their
patients. With no fear of retribution, Phil shared his honest informed opinions with his DCMS colleagues and with the community they
served. In his honor, the DCMS Board of Directors established the Philip H. Gilbert Invited Editorial to celebrate his spirit for addressing
issues that he championed such as advocacy, tort reform, community activism and caring for the underserved.
The “Request for the 2011 Philip H. Gilbert Invited Editorial” invitation was sent in July to local, state, and national leaders (physician or
layperson). All editorials received were reviewed by the DCMS Journal and Communications Committee. Two editorials were chosen for
publication - one in this issue and the other in the Winter journal.

As physicians, we have an important role to play in caring
for our patients. In addition, it is crucial that we are involved
in decisions made as our nation addresses rising health care
costs. Physicians must persuade Congress to strategically address health care costs while also improving the value of health
care instead of implementing across-the-board funding cuts
to Medicare and Medicaid that would prove detrimental to
patient care and physician practices. Particularly in Florida,
where the state is already enacting its own cuts to Medicaid,
additional cuts to Medicaid and Medicare would make it
harder for patients to get the health care they need.
Our nation’s broken medical
liability system weighs heavily on
health care costs – every dollar
that goes toward medical liability
is a dollar that does not go toward
patient care. A Harvard study reported that 40% of closed claims
lack any evidence of a medical error or patient injury. Closed claim
data from the Physician Insurers
Association of America shows
that nearly two-thirds of claims
Cecil B. Wilson, MD
against physicians that closed in
AMA Immediate
2009 were dropped, withdrawn
Past-President
or dismissed. The defensive medicine engendered by a dysfunctional medical liability system
increases the cost of health care $70 to $126 billion annually
according to a 2003 government study. Instituting proven
reforms should be included in any plan to address health care
costs. The American Medical Association strongly supports
medical liability reforms consistent with those working in states
around the country because they have proven to be effective.
Florida, like the nation as a whole, is plagued by chronic
conditions like heart disease, obesity, diabetes and smokingrelated diseases. In fact, 78 percent of the $2.5 trillion spent
annually on health care is for treatment of largely preventable
chronic diseases such as these.
To address these cost-drivers, physicians can encourage
healthier lifestyles and patients can do their parts to incorporate

8 Vol. 62, No. 3 2011 Northeast Florida Medicine

positive changes into their daily routines, improving their
health and wellness and reducing the incidence of preventive
illness. The AMA is taking an active role in fostering patientphysician partnerships to encourage healthy behaviors. The
AMA’s Healthy Life Steps program addresses key patient
behaviors like diet, physical activity, tobacco and risky alcohol
use, providing information and resources to help physicians
and patients work together to promote longer, healthier lives.
Reducing administrative overhead also has the potential to
decrease costs while simultaneously improving patient care.
The Centers for Medicare & Medicaid Services annual National Health Expenditures Accounts reports administrative
expenditures exceeding $160 billion in 2009. Administrative
costs do not contribute to patient care, and standardizing
processes and formats across different types of insurance and
health care systems can result in significant cost-savings. Administrative simplification has the added benefit of allowing
physicians to spend more time with patients and less time
burdened by red tape.
Finally, new models for health care delivery that reimburse
physicians for services that promote optimal patient care can
help ensure that the right patient receives the right care at the
right time, reducing costs associated with duplicative tests,
hospital readmissions and preventable illnesses. Physicians
are uniquely positioned to lead efforts in care coordination
and delivery reform, and the AMA is committed to ensuring
that physicians lead in developing new models of patient
care, including Accountable Care Organizations. These
patient-centered, physician-led approaches to new models
of health care have the potential to improve patient access
to high-quality, cost-effective care.
While there is no single solution to addressing health care
costs, it is clear that across-the-board cuts to health care spending are not the answer. Instead, we must strategically tackle the
areas that provide an obvious opportunity for improvement.
Our ultimate goal should be to achieve better value for our
health care spending by looking at opportunities in all areas
of our health care system, including the enactment of medical
liability reform, focusing on prevention and wellness, reducing
administrative burdens, and improving health care delivery
models. The AMA will continue to be a leader in these efforts.

www . DCMS online . org

Residents’ Corner: UF Health Science Center - Jacksonville
Editor’s Note: In an effort to connect more Duval County Medical Society members with residents, in each 2011 issue there will
be a “Residents’ Corner” with information about a residency program in the area, details about research being done and/or a list of
achievements/accomplishments of the program’s residents. This “Residents’ Corner” features University of Florida Health Science
Center - Jacksonville.

Overview of Residency Program

Under the direction of Dr. Robert Nuss, Dean of Jacksonville’s Regional Campus, Dr. Constance Haan, Senior Associate Dean
for Educational Affairs, and Dr. Frank Genuardi, Associate Dean for Student Affairs, the University of Florida Health Science
Center – Jacksonville (UFHSCJ) is growing with 27 Accreditation Council for Graduate Medical Education (ACGME) accredited residency and fellowship programs and one Commission on Dental Accreditation (CODA) accredited residency program.
In partnership with Shands Jacksonville Medical Center, more than 300 residents and fellows train in these programs, making
this the third largest postgraduate medical training program in Florida. In addition, an anesthesiology residency program under
the direction of Department Chairman Dr. Moeen Panni is getting underway this month.
The UF & Shands Jacksonville medical complex of today began as Duval Hospital and Asylum in 1870, as Florida’s first nonmilitary hospital. After the merger of several hospitals and name changes, in 1999 it became Shands Jacksonville. It is now the
home of the University of Florida Proton Therapy Institute and Shands’ nursing staff was granted Magnet® recognition by the
American Nurses Credentialing Center for nursing excellence this year. Also this year, the Shands Jacksonville Medical Center
was awarded the prestigious Governor’s Sterling Award for Sustained Performance Excellence.

Also, Dr. Rosalyn Alcalde, an endocrinology Fellow, received two $5,000 Dean’s Grants for her research in July 2010, entitled “Inhibition of endoplasmic reticulum stress in endothelial cells by high-density lipoprotein” and “Acute effects of hookah
smoking on hormonal and metabolism parameters: a pilot study.”
Resident Honors
The University of Florida School of Medicine – Jacksonville (UFCOMJ) is proud of its residents' accomplishments. Dr.
Michelle Stalnaker, an obstetrics and gynecology Resident, received the Outstanding Resident Teacher Award at the Medical
Education Banquet on February 22, 2011 in Gainesville, FL.
Each summer brings the end of the academic year for UFCOMJ and at a June 22, 2011 ceremony, faculty and staff gave 97
physicians their certificates of completion. The following awards were bestowed: Esenam Lucinda Kjerulff, MD (Obstetrics and
Gynecology), the College of Medicine Excellence in Student Education Award; Shawn Tai, MD (Internal Medicine), the Edward
Jelks Outstanding Resident Clinician Award; Christopher Y. Hopkins, MD (Surgical and Critical Medicine), the Rosilie O.
Saffos Outstanding Resident Teacher Award; Matthew Christopher Lee, MD (Orthopaedic Surgery), the Ann Harwood-Nuss
Resident Advocate Award and Alejandro Jesus Garcia, MD (General Surgery), the Louis S. Russo, Jr. Award for Outstanding
Professionalism in Medicine.
Residents’ Corner written by: Dr. Jeannine Mauney, a recent graduate from the obstetrics and gynecology residency at the University of Florida
College of Medicine – Jacksonville. Dr. Mauney served as UFCOMJ’s resident representative to the DCMS Board of Directors for the 2010 –
2011 academic year. She is a graduate of the Wake Forest School of Medicine and is entering private practice in Jacksonville, FL.

www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 9

Northeast Florida’s leader
in mental health care.
Baptist Health provides the full
continuum of behavioral health needs
for the Northeast Florida region.
We offer a broad array of services
for children and adults, including
psychiatric assessments and medication
management, neuropsychological
testing and psychological evaluations,
and psychotherapy for issues ranging
from simple adjustment to life events to
life-long mental health disorders.

“As with any other illness, sometimes
people with mental illness need
hospitalization,” says Michael Solloway,
MD, Psychiatrist, Medical Director,
Baptist Behavioral Health. “We’re
fortunate to be able to have this beautiful
inpatient facility, helping patients stay
close to home so family members can
easily be part of the healing process.”

Our multidisciplinary team includes
psychiatrists, psychologists,
neuropsychologists, mental health
counselors, marriage and family
therapists, and social workers. We
have specialists on board who provide
treatment for addictions, autism and
Asperger’s syndrome, mood and anxiety
disorders, emotional wellness and more.

Mental Health Disorders Important to Recognize and Treat
I am honored to be the Guest Editor for this issue of Northeast Florida Medicine. As the Chair of the Department of Psychiatry at the University of Florida College of Medicine- Jacksonville, it is my pleasure to bring you this issue on mental health
disorders. Psychiatric and behavioral disorders are often under-represented topics outside of specialty journals despite the fact
that they constitute a highly prevalent group of disorders. It has been estimated that between 15% and 25% of adults currently
suffer from a mental disorder1. In fact, the World Health Organization (WHO) has estimated that mental disorders rank third
in global disease burden after respiratory and cardiac disorders2. The WHO has also projected that
depression will be the second leading cause of disability worldwide by 20201.
So mental and behavioral disorders are widespread, highly prevalent, and cause significant
morbidity. A large number of your patients will be affected, and so it is important for you to be
aware of psychiatric disorders and to be able to screen patients, provide primary care for mental
disorders, and to know when to refer to a specialist. The goal of this issue is to provide you with
guidelines to be able to carry out these responsibilities for some selected disorders, in addition
to becoming aware of the plight of the seriously mentally ill regarding social and medical needs.
The lead article in this issue, “Alone in a Crowded Room: The Continuum of Post-Traumatic
Stress” was written by Tracy Hejmanowski, PhD and me. It explores the impact of combat trauma
on service members and veterans. In this article we discuss post-traumatic stress symptoms, the
impact a veteran’s response to trauma has on their family members, and evaluation and treatment
of veterans of combat. This article is approved for Continuing Medical Education (CME) credit.

Steven P. Cuffe, MD
University of Florida
College of Medicine - Jacksonville “Youth Non-Suicidal Self-Injury: An Overview for Primary Care Physicians,” was written by
Department of Psychiatry
Gabriella DePrima, PsyD, and Stephanie Sims, MD. This article examines a highly prevalent

and disturbing set of behaviors ranging from less serious scratching and pinching to serious forms
of cutting and burning and discusses the epidemiology, causes, and psychiatric disorders associated with these behaviors in our
youth. In addition, the authors provide a template for screening and triage of youth displaying these behaviors.
Richard Christensen, MD, MA, wrote “Clinical Considerations in the Treatment of Mentally Ill Homeless Persons.” In
this article he discusses the most common barriers to accessing psychiatric and primary care for homeless persons and explores
the devastating effects co-morbid disorders can have in persons struggling to avoid, or escape, homelessness. He concludes by
proposing an integrated model of care to better meet the clinical needs of this highly undeserved population.
Finally, “The Medical Home: Treating Psychiatric Disorders in the Primary Care Setting,” explores the concept of the “medical
home” and how changing to this model can enhance the treatment of mental disorders in the primary care setting. Brian Celso,
PhD; Kenyatta Lee, MD; Chirag Desai, MD and Eric Steward, MD, describe the medical home model at the University of
Florida College of Medicine-Jacksonville and the initial collaboration in the treatment of anxiety disorders which was undertaken.
I hope you find this issue interesting and helpful to you in your work with patients.
Resources:
1)Bromet EJ, Susser E. The burden of mental illness. In Psychiatric Epidemiology, E Susser, S Schwartz, A Morabia, EJ Bromet eds. New York:
Oxford University Press, 2006, pp. 5-14.
2)Ustun TB. The global burden of mental disorders. Am. J. Public Health. 1999, 89:1315-1318.

'Last Roll Call' Photograph Honors Fallen Marine
LCDR Ken Meehan PA-C., Battalion Surgeon 1st LAR,
1stMARDIV, is the photographer for this issue’s cover. He has
completed four combat tours in Iraq and Afghanistan and is
currently assigned as the Division Officer for the Department
of Orthopaedics, Naval Hospital Jacksonville where he works
as an Orthopaedic Physician Assistant.
Entitled “Noble Last Roll Call,” the photograph was taken
in Rawah, Iraq, July 27, 2007 to honor Hospitalman Daniel
S. Noble, 21, of Whittier, Calif., who died July 24, 2007 as a
result of enemy action while conducting security operations
in the Dilaya Province, Iraq. He was permanently assigned to
the 1st Marine Division, Fleet Marine Force Pacific, Camp
Pendleton, Calif. Ken said, “Daniel is still missed by everyone
who knew him.”
Ken recalls, “HN Noble was in my battalion, but I had
assigned him to support another unit that had suffered greater
combat losses after we arrived for our tour of duty in Rawah,
Iraq. When we got word he was killed in action, we said our
good-byes in standard Marine fashion by conducting a last
roll call.”
Ken explained, “Back in the day, roll call was conducted
every morning to ensure accountability. Traditionally, a
member’s name would be called out by the company First
Sergeant three times before the person was marked as absent.
So now when a Marine is killed in action, fellow warriors
gather together for a symbolic ‘last roll call’ of the fallen and
the Battalion roster is read out loud. After the first call of
the member’s name, a pair of combat boots is placed before
a stack of sandbags. At the second reading of the name, the
member’s rifle is fixed with its bayonet plunged into the bags.
And when the name is called for the third and final time, the

member’s helmet is placed atop the rifle, forming a combat
cross. At the conclusion of the ceremony, the battalion files
past in single file to pay last respects.”
After taking the photo, Ken stylized it so it appeared as
a piece of art. Using deep orange and red tones, he was able
to “convey the heat of the desert averaging 130-140 degrees
by late afternoon and the solitude one can feel even when
standing among a few hundred people." Ken added, “In full
combat gear, you are sweating so hard that your tears are
washed away as quickly as they form.”
Raised near Boston, MA in Medford, Ken became interested
in photography when he was 5-years-old. His first camera
was “a Brownie complete with disposable flash cubes.” When
he was 13-year-old he bought his “first real camera”, a Single
Lens Reflex Cannon AE1 that cost him his “life savings” of
$350. He still has that camera.
He remembers, “Growing up I wanted to be an artist
but never really had a talent with pen or brush. The word
‘photography’ literally means to draw with light, and with
my camera I realized that I could paint on a canvas of film. I
see my photographs as a myriad of expressions. For me some
are eternal stories, others emotions suspended in time and
sometimes they are my truth untold.”
Next year Ken will reach the 30-year mark in his Navy
career, joining when he was only 17-years-old. For 16 years
he was a Hospital Corpsman and then in 1998 received his
commission into the Medical Service Corps. Congratulations
to Ken for reaching this milestone and a sincere thank you
to him and all our military personnel around the world who
put themselves in harm’s way protecting the freedoms we
enjoy in America.

Reflections

LCDR Ken Meehan in Al Qiam, Iraq, Christmas Day 2004

12 Vol. 62, No. 3 2011 Northeast Florida Medicine

The bloody stains of my boots
have faded with the sun
Yet I remain cloaked in a
robe of stolen honor

Raging between Pride & Sorrow
my soul is engulfed in flame
The ashes of the dead
cloud my mind

O' what great pity we reap
upon ourselves when
dreams and hope fade
from the sun
Ken Meehan
www . DCMS online . org

Alone in a Crowded Room: The Continuum
of Post-Traumatic Stress

Background - Benefits that Matter!

The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education
(CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain
medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani,
MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS.
This issue of Northeast Florida Medicine includes an article, “Alone in a Crowded Room: The Continuum of Post-Traumatic Stress”
authored by Tracy Hejmanowski, PhD and Steven P. Cuffe, MD.(see pp. 15-19), which has been approved for 1.0 AMA PRA Category
1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http://
www.dcmsonline.org/cme_requirements.aspx).

Faculty/Credentials: Tracy S. Hejmanowski, PhD, is a Clinical Psychologist and Program Manager of the Deployment Health Center,

Naval Hospital, Jacksonville. She did her MA and PhD degree work in Clinical Psychology at the University of Connecticut, Storrs.
Steven P. Cuffe, MD, is Professor and Chair, Department of Psychiatry, University of Florida College of Medicine, Jacksonville. He
received his medical degree from Bowman Gray School of Medicine of Wake Forest University, interned at Herrick Hospital & Medical
Center, Kaiser Permanente Hospital in Oakland, California and did a General Psychiatry Residency at the University of California,
as well as a Child Psychiatry Fellowship at UC.

Objectives for CME Journal Article
1. Understand the impact of combat-related trauma on military service members, veterans and their families
2. Recognize the major PTS symptoms in military service members and veterans exposed to the horrors of combat
3. Learn the components of an evaluation of PTS symptoms
4. Understand the major modalities for treatment of PTS disorder, including use of medications and psychotherapeutic techniques

1. Read the “Alone in a Crowded Room: The Continuum of Post-Traumatic Stress” article on pages 15-19
2. Complete the Post Test and Evaluation on page 14
3. Fax the Post Test and Evaluation to DCMS (FAX) 904-353-5848 OR members can also go to www.dcmsonline.org & submit test online

CME Credit Eligibility

In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if
a passing score is not made on the first attempt. DCMS members and non-members have two years to submit the post test and earn CME credit.
A certificate of credit/completion will be emailed, faxed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact
the DCMS at 355-6561, ext. 103, or llegacy@dcmsonline.org.

Faculty Disclosure Information

Dr. Hejmanowski and Dr. Cuffe report no significant relationships to disclose, financial or otherwise with any commercial supporter or product
manufacturer associated with this activity.

Disclosure of Conflicts of Interest

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content
of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified
conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and
educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the
Florida Medical Association to provide continuing medical education for physicians.The St. Vincent’s Healthcare designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.

(Return by September 2, 2013 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org)
1. One of the most important transitions for post-deployed service
members is:
a. Establishing a new routine
b. Getting accustomed to work in peacetime
c. Developing a coherent self-identity
d. Staying in touch with those still deployed

6. Which is the most important to consider when evaluating a
combat veteran?
a. Veterans will expect to be seen on time
b. Veterans usually have no difficulty trusting medical professionals
c. Veterans may be guarded & it is critical to establish a
connection with them
d. Veterans value straightforward communication

2. Some of the most troubling aspects of psychological readjustment 7. Family members of veterans:
have to do with:
a. Are not typically impacted by war or deployment
a. Guilt and regret
b. Rarely struggle with depression, isolation or anxiety
c. Can experience difficulty with the readjustment period after
b. Anger
deployment
c. Grief
d.
Are not an essential part of the veteran's transition back home
d. All of the above

3. What is true about PTS and post traumatic growth? (PTG)
a. PTS is more common than PTG
b. PTG is more common than PTS
c. PTS and PTG can co-exist
d. PTS and PTG cannot co-exist
4. The three hallmark symptoms of PTSD include:
a. Startle, hypervigilance and insomnia
b. Re-experiencing, avoidance & numbing, and hyperarousal
c. Anger, sadness, remorse
d. None of the above
5. When assessing war veterans, it is important to evaluate for:
a. Concussive events
b. Alcohol use, risk-taking, and aggressive behaviors
c. Adequacy of sleep
d. All of the above

8. Among the most effective treatment modalities for those with
operational stress are:
a. Complementary and alternative medicine (CAM)
b. Exposure-based therapies
c. Both a and b
d. Neither a or b
9. Which is the medication of choice to treat most PTS symptoms?
a. Risperidone
b. Sertraline
c. Propranolol
d. Alprazolam
10. Which medication has been shown in placebo controlled trials to
reduce nightmare and promote sleep?
a. Prazosin
b. Zolpidem
c. Trazodone
d. Diphenhydramine

Evaluation questions & CME Credit Information



(Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree)
The article met the stated objectives:
1
2
3
4
5
The article was appropriate to my practice:
1
2
3
4
5
The topic was current and well presented:
1
2
3
4
5
Comments:______________________________________________________________________________________
____________________________________________________________________________________________
Name (Print)___________________________________________Email_____________________________________
Address/City/State/Zip_____________________________________________________________________________
Phone__________________________Fax_____________________DCMS Member (circle)

Alone in a Crowded Room: The Continuum
of Post-Traumatic Stress
Tracy S. Hejmanowski, PhD and Steven P. Cuffe, MD
“War is delightful, to those who have no experience of it.”
Desiderius Erasmus, 15th century
“Nobody wins in a war; there are only varying degrees of losses.”
Michele Baugh, daughter of KIA Vietnam Veteran, 20th century
“No one is really unscathed from war unless you have no
compassion for human life.”
COL John Bradley, 21st century

Abstract: Post-traumatic stress disorder (PTSD) is quite

common among military service members and veterans who
have served overseas, given their frequent and repeated exposure to the horrors of combat. Responses to such trauma
should be viewed on a continuum, with varying degrees of
biological and emotional manifestations that can lead to interpersonal consequences. This article explores the impact of war zone
trauma on veterans and their families and provides a guide for physicians on the diagnosis and treatment of post-traumatic stress.

Casualties of War

The quotes above, taken from various points in history,
reveal the timeless universality of the impact of war upon
those who fight and those who care for our nation’s warriors
upon their return. War veterans (a term that includes active
duty, veterans, guardsmen, and reservists alike) understand
the inherent truth in these statements, for they have felt firsthand the intense pride, relief, horror, fear, love, and hatred
that encompasses war.
The phenomenon of war trauma has existed for as long
as wars have been waged. In his epic poem, “The Odyssey”,
Homer portrayed Odysseus, a strong and courageous warrior
who became plagued by the trauma of war.1 Similar experiences
are felt by veterans of World War I and II, Korea, Vietnam,
and the wars in Iraq and Afghanistan. War veterans, regardless of their training, personality, psychological resilience,
stoicism, and belief system, return from war changed – for
the better, for the worse, or a little of both. Veterans who
struggle with war-related stress echo a familiar chorus that
war haunts them long after its end.
Of the more than two million service members who have
served in the wars in Iraq and Afghanistan and neighboring
Address correspondence to: Tracy S. Hejmanowski, PhD, Clinical
Psychologist and Program Manager of the Deployment Health
Center, Naval Hospital, Jacksonville, 2080 Child Street, Bldg 964,
Branch Health Clinic, Jacksonville, FL 32214. Phone: 904-5423500 x8837. FAX: 904-542-0007. Email: Tracy.Hejmanowski.
ctr@med.navy.mil.
www . DCMS online . org

countries since 2003, over 6,000 service men and women have
sacrificed their lives for their country. Nearly 43,000 veterans
of Iraq and Afghanistan have been wounded (ranging from
shrapnel injuries to amputation to traumatic brain injury).
Well over 100,000 service members have witnessed one or
more traumatic events that have caused horrific injuries to
or tragic deaths of their comrades in arms. All of them have
sacrificed their life as they once knew it.2 And while our nation’s heroes serve in war zones overseas, there are over one
million military spouses, two million children, and countless
extended family members who have maintained the stability
of the family as they witness the toll that war takes on their
loved ones.3

The Impact of Trauma

For those military men and women who are fortunate to
return home, many carry with them the impact of memories
that, in some cases, damage the psyche. Bob Cagle, a Vietnam
veteran, once said, “PTSD is not a reasonable diagnosis for
something so encompassing that it can and will engulf a
person’s life, ruin any chance for intimacy, keep horrid scenes
in one’s mind for [decades] or for life in the case of other
poor souls. To be angry at the world, jump at the slightest
sound or quick movement, and live within one’s own mind
because you know that no one would understand or try to
help is to live in hell.”1
It is common for veterans to describe living in society as
being “alone in a crowded room.” They often feel unable to
relate to civilians, including their own families. They feel their
ability for true connectedness is lost, except when they are
with their comrades, which leads to a sense of loneliness and
isolation. From the perspective of veterans’ families, they also
can feel ‘alone in a crowded room’ when they experience the
emotional distance from their veteran loved one. The ‘crowd’
this time refers to those comrades and souls carried in the
veteran’s heart and mind that may command the veteran’s focus.
All veterans who return from war experience some degree
of change to their beliefs, priorities, philosophy, perspective,
and/or personality – essentially their sense of identity is altered. Whereas post-traumatic symptoms have been shown to
result in biochemical and neurological changes and impairments in cognitive functioning, the impact of war also has a
more intangible consequence that has been referred to as an
existential or soul injury.1 This injury, although often at the
crux of combat stress, has not been delineated in the formal
diagnostic nomenclature to date.
The most important task for veterans in their journey
back from war may be the development of a coherent and
well-integrated self-identity.1 War’s impact on one’s sense of
Northeast Florida Medicine Vol. 62, No. 3 2011 15

meaning, purpose, direction, and self-esteem compromises
the ideal of the self. This injury may manifest in complicated
grief, fueled by the moral ambiguities and imperatives of war,
including killing, violence against noncombatants (especially
children), and violations of the rules of engagement. It is the
veterans’ defensive mechanisms of dissociation and somatization that result from repeated trauma which compromise the
attainment of this coherent self.1
Some trauma transforms into complicated grief, survivor’s
guilt, regret, or shame. The rumination about the what-if ’s and
if-only’s sometimes exist as a perpetual presence in veterans’
consciousness as they try to undo the events and actions in
which they participated or in which they witnessed humanity’s
darkness. Veterans’ war-time exposure can cause them to be
anxious and somatic in the presence of emotionally-charged
triggers and lead them to be sentimental and sensitive to
situations involving injustice and dishonor.
For our nation’s warriors, their psychological wounds impact
not only their quality of life, but that of their family. Many
family members are often ill-prepared for and unaware of the
repercussions of their loved one’s exposure to the hellish conditions that may have cost others their lives and their veteran’s
sense of safety and peacefulness. Whereas the dissociative
symptoms, sleep disturbance, and sexual problems mostly
impact intimate relationships, veterans’ anger and emotional
distancing has a profound impact on their children.4,5

Post-Traumatic Growth
Not all sequelae from war have a negative valence, however.
Although much of the focus of literature on the impact of
war has been biased toward understanding post-traumatic
stress, some of the cognitive and emotional shifts that result
from difficult experiences can provide inner strength —
­ what
has been called post-traumatic growth.6 Some traumatic
events provide a renewed focus and purpose in life that guide
veterans along a meaningful path. This can take the form of
maximized empathy, optimism, a more neutral perspective,
clearer purpose, and motivation to give to others. Many clinicians and researchers agree that an individual can experience
both post-traumatic stress and post-traumatic growth out of
the same events.6

The Continuum of Post-Traumatic Stress
PTSD was first recognized as a psychiatric diagnosis in the
Diagnostic and Statistical Manual (DSM) in 1980, classified
as a stress and anxiety disorder. The hallmark symptom clusters
of PTSD include: 1) re-experiencing of the traumatic event in
the form of intrusive images, nightmares, dissociative events
such as flashbacks, and physical signs of distress (not unlike
those manifested during a panic episode), 2) hyperarousal in
the form of insomnia, hypervigilance, irritability, edginess
and restlessness, and 3) emotional numbing and avoidance
of potential triggers that might lead to recall of past traumatic
events that could potentiate muscle memory responses or
emotional reactivity.7
16 Vol. 62, No. 3 2011 Northeast Florida Medicine

The nature of the wars in Iraq and Afghanistan forces an
unnatural recalibration of security and sanity. In places where
innocent civilians are used as human shields, children are
used as bait for an attack, and ordinary moments can turn
extraordinarily devastating in seconds, veterans’ fundamental
belief systems become altered. Upon reintegration, veterans
may assess and assume the presence of non-discriminating
threats in even the most benign circumstances. It is difficult
to convince a veteran to dial back their level of vigilance and
situational awareness, for they have known the randomness
of violence, they have fought to keep their comrades alive,
and they will do whatever it takes to avoid ever being caught
unaware. It is the proverbial sheepdog who will always set the
perimeter around the flock of sheep, even when the wolves
are not visibly present.8
The most prevalent complaints among returning war
veterans include somatic, emotional, cognitive, behavioral, interpersonal, and psychosocial components. Somatic
concerns include primary and middle insomnia, fatigue,
headaches, tinnitus, impotence, restlessness, and chronic
pain. Emotional and psychological complaints may involve
nightmares, racing thoughts (particularly at bedtime), generalized and social anxiety, anger and irritability, impulsive
hostility, emotional numbing, hypervigilance, complicated
bereavement, and despair.
Cognitive problems include poor sustained and divided
attention (in part due to continual scanning of the environment), poor concentration, impaired memory, rumination,
and distorted thinking (e.g. jumping to conclusions, dichotomous decision-making).9 Common, yet underreported
behavioral problems include abuse of alcohol, illicit drugs,
and prescription medication and risk-taking behaviors (e.g.,
reckless driving, starting fights). Interpersonal concerns
include feeling misunderstood, being intolerant of others,
distrust, isolation, and withdrawal. Psychosocial concerns
may involve spiritual crisis, domestic violence, child abuse,
and general family dysfunction.
The most likely concerns of veterans who present to physicians include anger, sleep problems, and erectile dysfunction
– all of which can be complicated by substance abuse. All
of these clinical presentations can be influenced by the individual’s characterological constitution, cultural sensitivities,
or pre-existing life trauma that can serve as an additional
vulnerability.
Veterans often report their sensitivity to triggers, which
include those that stimulate each of the basic sensory modalities (e.g., sudden or loud sounds, noxious or unusual
smells, high temperatures, foreign foods, or uneven terrain).
However, triggers that also produce anxiety, panic, fear, anger,
and overall sympathetic nervous system arousal include less
concrete stimuli, such as situations deemed unpredictable (i.e.,
crowds), with minimal controllability (i.e., a room without
an easy exit), or foreboding of potential danger (i.e., traffic
or building complexes).
www . DCMS online . org

Triggers can snap a veteran back into the muscle memory
of the combat condition, ready to fight, aggress, and escalate
– none of which are appropriate in the civilian milieu. And
for some, the combat condition gets stuck in the “on” position, such that they cannot easily turn off their defensive or
aggressive posture. For some, this heightened state of arousal
serves as an artifact of war, such that the adrenaline rush of
battle becomes addictive and leads some veterans to seek
behaviors or environments that maintain that high.

The Threshold for PTSD

Although a war veteran may experience many of these earlier
mentioned hallmark symptoms of post-traumatic stress, the
threshold for rendering a diagnosis of PTSD depends on the
degree of functional, psychological and emotional impairment
that it causes. Without clinically significant impairment in the
social and/or occupational functioning of the individual, the
diagnosis may be more indicative of an Adjustment Disorder,
Anxiety Disorder, Depressive Disorder, or Complicated Bereavement. Many veterans operate as “functionally stressed”
in their life, much like a workaholic functions at the office.
It is common for PTSD to be diagnosed by physicians
who do not specialize in behavioral health. In some cases, a
patient who reports one or two symptoms of post-traumatic
stress, such as nightmares and insomnia, may quickly be diagnosed with PTSD. In other cases, the diagnosis of PTSD
may be overlooked as part of the diagnostic differential, when
neurocognitive complaints are prominent, suggestive of traumatic brain injury. Likewise, neurovegetative symptoms (e.g.,
depressed mood, sleep problems) that are more disruptive
to the individual’s daily functioning may overshadow classic
PTSD symptoms.
It is not uncommon for PTSD to be diagnosed by providers
who do not specialize in behavioral health. In some cases, a
patient who reports one or two symptoms of post-traumatic
stress, such as nightmares and insomnia, may prematurely
or erroneously be diagnosed with PTSD. In other cases, the
diagnosis of PSTD may be overlooked as part of the diagnostic
differential, when neurocognitive complaints are prominent,
suggestive of traumatic brain injury. Likewise, neurovegetative symptoms (e.g., depressed mood, sleep problems) that
are more disruptive to the individual’s daily functioning may
overshadow classic PTSD symptoms.
As the nuances of military operational stress disorders are
complex and the implications for diagnosis are broad with
regard to disability compensation and treatment management, it is advisable for physicians to screen for impairment
caused by symptoms of operational stress, while deferring
formal diagnosis to behavioral health specialists who have
experience working with military personnel.

Biomechanical Injury

In addition to the psychological trauma incurred in war,
the most common cause of physical injury from fighting in
Iraq and Afghanistan is “biomechanical trauma” to the brain
caused by explosions and blast waves.10 Traumatic brain injury
www . DCMS online . org

(TBI) symptoms fall into three categories: cognitive (e.g.,
memory, poor attention, limited concentration), emotional/
behavioral (e.g., irritability, depression, anxiety, dyscontrol,
isolation), and somatic (e.g., insomnia, headache, tinnitus,
dizziness). Patients who have experienced mild TBI are at
increased risk for psychiatric disorders (e.g., PTSD, depression, anxiety, substance abuse, suicide) as compared to the
general population.10
An adequate history of the mechanism of injury may not
be possible, due to the often chaotic nature of TBI events in a
war zone and the tendency of service members to overlook or
be amnestic for non-evacuating concussive events. However,
it is crucial when assessing a veteran to consider the severity
and type of the injury (as well as prior history of brain injuries) and to what extent symptoms consistent with traumatic
brain injury overlap with PTSD to provide a more holistic
diagnostic picture. The overlap of symptoms for PTSD and
TBI include depression, anxiety, irritability/anger, trouble
concentrating, fatigue, hyperarousal, and avoidance.10

Safety

Across all modern wars, inclusive of those in Iraq and Afghanistan, more veterans of war have taken their lives through
suicide than have been killed on the battlefield. For the Army
and Marine Corps in particular, the military suicide rate has
surpassed that of the general population since 2007.11 The
military has responded with more aggressive efforts to assess
and prevent suicidal behavior.
Many causal models of suicide include the predictive
variables of depression, relationship strain, financial and occupational loss, and degree of life impairment.12, 13 Clinically
speaking, it is the presence of overwhelming negative thoughts
and a sense of hopelessness over the future that potentiates
suicidal behavior.
Another safety concern to address among veterans is the
potential for harm to others, including family members and
community members. A small proportion of veterans dealing
with impulse dyscontrol and irritability may unconsciously
or consciously seek opportunities to enact their aggression
against others. A study by Riggs, Byrne, Weathers, and Litz
(1998) found that 63% of veterans seeking help for PTSD
had been aggressive to their partners in the last year.14
With regard to concerns for both suicidal and violent potential, it is important for physicians to assess the authenticity
of a veteran’s supportive network (including fellow veterans),
their access to lethal means of self-harm, their history of
impulsivity and substance use, the sufficiency of their sleep,
their medication regimen, and their outlook on the near and
distant future. During this assessment of risk, the physician
has an opportunity to directly connect the veteran with
various support and community service organizations and
utilize case management services at the Vet Center, VA, and
community veteran service organizations.
Northeast Florida Medicine Vol. 62, No. 3 2011 17

Treatment Modalities

The modalities of treatments for PTSD vary widely.
Empirically-validated treatment protocols exist for exposurebased treatments (e.g., Prolonged Exposure Therapy and Stress
Inoculation Training), and cognitive therapies (e.g., Cognitive
Behavioral Therapy and Cognitive Processing Therapy). An
additional empirically-validated treatment protocol, albeit
one that is relatively more controversial, is Eye Movement
Desensitization and Reprocessing.15
These validated treatment methods tend to be structured
and modularized, which has received some criticism from
those who propose a more humanistic and emotionally
validating approach. Group and family therapies are known
to be very beneficial to both veterans and family members
alike, by assisting with the transition back into their personal
and public lives, through taking a systems approach to care.
Complementary and Alternative Medicine (CAM) therapies
have also been shown to be effective as adjunctive elements to
comprehensive PTSD treatment. These include art therapy,
acupuncture and acupressure, massage, yoga, meditation,
and animal-assisted therapies (e.g., equine therapy, service
dog placement).16
Pharmacotherapy is helpful for some veterans to treat
symptoms of PTSD (nightmares, avoidance or hyperarousal
symptoms), depression, and/or anxiety.17 This is usually done
in combination with psychotherapeutic interventions. Antidepressants such as serotonin and serotonin/norepinephrine
reuptake inhibitors (sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, duloxetine) are usually the first choice for
treating veterans since they can target symptoms of PTSD,
depression and anxiety.17 Sertraline (dosed up to 200 mg) and
fluoxetine (dosed 20-80 mg) have the best research base and
are FDA approved for the treatment of PTSD. Side effects
of these medications include an initial risk of increased irritability, thus the veterans should be monitored more closely
at the beginning of treatment. In addition, gastrointestinal
and sexual side effects are common and should be discussed
with the patient.
Many other medications have been used to treat PTSD
symptoms with varying degrees of success. Interestingly,
while widely prescribed for patients with PTSD, benzodiazepines have not been shown to be very helpful. They have
shown little to no improvement in core symptoms of PTSD,
and only minimal improvement of anxiety symptoms.18, 19, 20
There are few controlled trials of other medications to treat
PTSD symptoms. There have been a few small trials of anticonvulsants in the treatment of PTSD. Studies of valproate,
carbamazepine, tiagabine and topiramate have shown mixed
results, which is disappointing since they follow relatively
positive results from some open trials.21 Positive trials showed
only modest at best, and many studies were totally negative.
No agent showed consistent positive results precluding any
recommendation to use them.
Low-dose risperidone and olanzapine have been shown in
small controlled trials to decrease irritability and psychotic
18 Vol. 62, No. 3 2011 Northeast Florida Medicine

symptoms in patients with PTSD.17 However, the risk of
metabolic side effects (weight gain, increased blood pressure
and lipids, increased risk of diabetes) should limit the use
of atypical antipsychotics to those patients with serious irritability or aggression.
Nightmares and other major sleep problems plague many
patients with PTSD. Encouraging results have been found
using the α1 antagonist prazosin. In a large double-blind,
placebo-controlled study Raskind et al. titrated up to as high
as 15 mg and found significant improvements in suppression
of nightmares, sleep quality and global improvement.22 The
dose should be started low (1 mg at bedtime), and slowly
titrated up to either symptom resolution or side effects preventing further increase. It is important to warn the patient
about possible orthostatic hypotension and the risk of falling
if arising too quickly. Evidence for pharmacological management of patients with PTSD thus points to a management
plan that starts with SSRI/SNRI medication and augments
with low-dose antipsychotic medications for serious agitation and irritability and/or prazosin for nightmares and sleep
disturbances.

The Need for Genuine Connection

Despite the significant change in availability of counseling
for Iraq and Afghanistan veterans and families and improvements in the culture of stigma around behavioral health
care, many veterans remain reluctant to seek psychological
treatment and are more likely to present to family physicians, emergency rooms, and outpatient clinics. Hence it
is vital to establish meaningful relationships with veteran
patients. Physicians need to keep in mind that war veterans
may downplay the degree of their impairment for various
reasons: 1) some military members’ occupations create a
stoic expectation that they will engage in activities prone to
psychological trauma (from infantry combat to impromptu
mortuary affairs to battlefield medical aid), 2) their training is
designed to prepare them for dangerous or threatening situations, 3) military and deployment culture and indoctrination
breeds stoicism and a machismo response, 4) veterans may
fear and deny their diagnosis or use avoidance behavior to
avoid discussing their war experiences, and 5) veterans may
fear a negative impact on their career options, although this
fear is unfounded.
Medics and corpsmen, for example, are exposed to some of
the most graphic and horrifyingly intense injuries and deaths
on the battlefield. Because they are relied upon for medical
support, as well as psychological, spiritual, and emotional
guidance, they believe in the need to “heal thyself ” and are
consequently less likely to seek assistance with the burden
they carry.
Establishing rapport with those who have experienced traumatic events can be tenuous, but it is essential. Since veterans
are trained as sensors to quickly size up people and situations,
physicians may observe constricted affect or guarded behavior
and assume a personality disorder or a defensive character
structure. If the veteran does not feel a physician is genuinely
www . DCMS online . org

invested in their well-being, the veteran will not share what
has been impacting their mind and body, let alone their heart
and soul. Although the veterans may prefer to focus exclusively
on symptoms, to the exclusion of the history behind them,
this precludes veterans sharing important details that can illuminate the psychological etiology of somatic complaints,
such as sleep disturbance, headaches, erectile dysfunction,
low energy or fatigue, and general malaise.
When conducting an assessment with veterans, it is important to address their connectedness with others (particularly
family), risk-taking behavior, home safety (e.g., weapons,
drinking), sense of honor and dedication as a veteran, sense
of being appreciated, degree of family knowledge about
their diagnoses, amount of stress related to parenting, impulse control (i.e., road rage), memory problems, and sleep
hygiene. Also important to assess is how the veteran’s family
is functioning and how this may be impacting the veteran.
Despite the behavioral and psychological concerns that can
trouble war veterans, it is also important to recognize their
strengths, some of which have resulted from post-war traumatic
growth. Veterans tend to be situationally aware and protective, reliable, committed, direct, respectful, and appreciative.
They often have tremendous inner strength and resilience and
persevere through adverse situations. Their tenacity serves as
a buffer against conditions that impact their quality of life.
It is essential that physicians caring for veterans conduct
regular and direct follow-up monitoring of symptoms and
co-morbid health concerns.15 Forewarning of potential unpleasant side effects from psychopharmacological treatment
(especially sexual side effects) can go a long way in developing
trust. A multidisciplinary treatment approach is ideal, with
the primary physician coordinating care and referring to
specialists as needed. Non-traditional modalities of therapy
(e.g., veterans’ support groups, bibliotherapy, creative arts
therapy) should also be considered as part of the treatment
regimen. It is highly recommended that non-behavioral
health physicians establish a good working relationship with
a military and trauma-trained therapist if working with this
most deserving veteran population.

havior and a coping technique utilized by many adolescents. Primary
care physicians must become aware of the epidemiology, comorbidities,
and risk factors for this behavior in order to properly screen patients for
this problem. This article will describe NSSI and provide guidelines
for assessment in primary care and information about pharmacological
and psychotherapeutic treatment options. A list of resources is included
at the end of the article for providers and patients to obtain further
information about NSSI.

Introduction

Due to its high prevalence of patients who deliberately
injure themselves, clinicians of different specialties should be
aware of the various aspects of this behavior. Many terms are
used to describe this phenomenon, including self-mutilative
behaviors, deliberate self-harm, self-injurious behaviors,
non-suicidal self-harm, non-suicidal self-damaging acts,
self-mutilation, parasuicide, self-wounding, suicide gestures
and non-suicidal self-injury (NSSI). The difficulty that
clinicians and researchers have encountered in labeling this
behavior highlights the baffling nature of its occurrence. We
will use the term NSSI to describe this behavior. This article
is intended to serve as an introduction to NSSI to help the
general practitioner identify, assess, and refer these individuals
for more specialized care.

Epidemiology

Primary care physicians and particularly pediatricians may
be the first to detect signs of self-injury. An understanding of
the typical characteristics of individuals who self-injure is an
essential component to adequate detection, screening, and
referral for further treatment.
Age – Overall, there is a greater risk of self-injury in adolescents and young adults. Studies show the usual age of onset
of self-injurious behaviors between 13 and 24 years of age.1-3
Prevalence – The rate of self-injury in the community has
been difficult to measure and reports in studies are highly
variable. The rate of self-injury among psychiatric and clinical populations is estimated at 40% to 61% of adolescents
in psychiatric inpatient settings and 20% within adult psychiatric patients.3,4 Studies that have examined community
adolescent samples have estimated NSSI ranges from 5.1%
to 21%.5-7 There is a 4% prevalence rate within the general
adult population.3,5
Address Correspondence to: Gabriela DePrima, Psy.D., Clinical
Lecturer, UF College of Medicine-Jacksonville, Department of
Psychiatry, 580 W. 8th Street, 6th Floor, Tower 2, Suite 6005, Jacksonville, FL 32209. Email: Gabriela.DePrima@jax.ufl.edu.
20 Vol. 62, No. 3 2011 Northeast Florida Medicine

Form of Self-Injury – Among adolescent self-injurers,
the most common form is skin cutting (14%-65%) with
self-hitting as the second most common (32.8%).6,7 Other
forms of self-injury include pinching, biting, scratching, and
burning. Many adolescents engage in multiple forms of NSSI
with one study citing more girls (28%) than boys (13%)
engaging in multiple forms of self-harm.8
Gender – In community studies there appears to be similar overall rates in men and women.9,10 Among adolescents
receiving psychiatric treatment, there is a clear gender disparity with adolescent girls more likely to self-mutilate than
boys.6 However, there is no clear pattern among the general
adolescent population with results varying from no gender
differences to greater self-injury among adolescent girls.6,8
Ethnicity – Several studies have identified greater rates
of self-injury in Caucasians than other ethnic groups.6,11,12
Frequency – There were no consistent findings across studies regarding frequency of NSSI among youth. Frequency
estimates varied from daily to only once among non-clinical
adolescents and many reported no longer engaging in this
form of behavior.6 Overall, it appears that for many adolescents
and young adults, NSSI may be time-limited.

Clinical Correlates

It is important for primary care providers to be aware of
potential comorbidities among patients who engage in NSSI.
Although many individuals automatically equate NSSI with
Borderline Personality Disorder, NSSI is only one symptom
that encompasses this condition according to the Diagnostic
and Statistical Manual of Mental Disorders-Fourth Edition-Text
Revision (DSM-IV, TR). Individuals who engage in NSSI are
a diagnostically heterogeneous population and may present
with various forms of psychiatric dysfunction ranging from
mood to anxiety disorders.
Depression/Anxiety – Individual who engage in NSSI have
been found to experience more intense and negative emotions
and score higher on measures of depression, anxiety, and
negative temperament.6,13,14 Some have suggested that anxiety
may be more strongly related to NSSI than depression due to
the emotional arousal or pressure present in anxiety that may
precipitate self-injury.14 Adolescents who have self-injured
report more depressive and anxious symptoms as compared
to those who do not self-mutilate.6 Specific prevalence estimates of the presence of Axis I diagnoses within outpatient
adolescents who deliberately self-injure is limited. A study
of inpatient adolescent populations yielded a prevalence
rate of 41.6 % for Major Depressive Disorder, 23.6% for
Post-Traumatic Stress Disorder, and 15.7% for Generalized
Anxiety Disorder.3
www . DCMS online . org

Suicide – Self-injury and suicide are two distinct behaviors
as they are clearly differentiated by intent, method, and psychological sequelae. Early studies have identified individuals
who self-injure to be at a greater risk for suicide attempts and
to have a higher probability of committing suicide after many
years of NSSI.15 However, recent studies have yielded mixed
results. Some studies indicated that people who engage in
NSSI do not have a greater risk for suicide and instead NSSI
represents a maladaptive coping behavior. These studies cite
evidence that many individuals who self-injure have never
attempted suicide or experienced suicidal thoughts.3,16 Other
studies concur with earlier research.8,16 These studies indicate
that 50% of individuals in community samples versus 70% of
inpatient psychiatric samples who partake in NSSI report at
least one suicide attempt.3,6 An additional study concluded
that adolescents who engaged in NSSI were six times more
likely to attempt suicide than those who did not report NSSI.17
Ultimately, it will be important for practitioners to assess for
suicidal ideation among those suspected of NSSI.

most commonly cited reasons for self-injury in adolescents.4,9
More specifically, this refers to the reduction of intense and
negative feelings. Commonly cited motives include, “I wanted
to get my mind off of my problems,” “to stop bad feelings,”
and “to manage stress.” The act of self-injury is often followed
by a feeling of calm.

Borderline Personality Disorder – It is often believed
that since self-injury is a symptom of Borderline Personality
Disorder (BPD), all individuals who self-injure must meet
criteria for this disorder. In fact, individuals who engage in
NSSI are considered a diagnostically diverse group and may
present with a variety of psychiatric conditions.3,9 There are
studies which show that individuals who engage in NSSI have
more symptoms of BPD than individuals who do not engage
in this behavior.3,13 Approximately 70 to 75% of individuals
with BPD exhibit self-injury.18

Resisting Suicidal Impulses – Self-injury is used as an
alternative to suicide and to manage suicidal urges. Inconsistencies exist among studies regarding the link between NSSI,
suicidal ideation, and suicide attempts.

Eating Disorders – Self-injury has been found to be more
common among individuals with eating disorders such as
bulimia and anorexia. A recent study that focused on a college
student population found a positive correlation between eating disorder symptoms and self-injury.19 It is speculated that
binging and purging may be preceded by negative emotions
that are similar to those that also precede self-injury. However,
some studies have not confirmed this link.20
Childhood Abuse – There has only been a modest relationship between childhood sexual abuse and NSSI, suggesting
that although child abuse may be an important factor for
some who self-injure, there are many individuals who have
experienced abuse who do not engage in NSSI.21
Substance Use – Individuals who have substance abuse
disorders have been found to be more likely to self-injure
than non-substance abusers.22

Purpose of Self Injury

NSSI is clearly differentiated from suicidal behavior as the
intent of NSSI is not to cause death. It may be difficult to
understand the underlying reasons for individuals who engage
in NSSI; however this is an important aspect of directing
treatment and it should be adequately explored. The many
functions of NSSI that have been identified through research
include the following:
Affect Regulation – Among the identified functions of
NSSI, this has been recognized by several studies as one of the
www . DCMS online . org

Self-Punishment – Self-directed anger is the second most
common function of self-injury.9
Interpersonal Influence – This function of self-injury
describes the social reinforcement that can be obtained from
this behavior. Examples include: gaining attention from peers,
caregivers, romantic partners, and authority figures. Individuals may self-injure to elicit help, affection, and acceptance,
and/or to avoid being abandoned or rejected. These motives
may be unconscious or conscious.
Anti-Dissociation – This emphasizes the desire that some
self-injurers have to stop dissociative experiences (e.g., depersonalization, de-realization) and feel “real” or “alive”.

Sensation Seeking – Self-injury is used as a way of generating excitement, exhilaration, or to experience a “high”.
The release of endogenous opiates has been speculated to
be triggered from repeated NSSI that may elicit feelings of
pleasurable physical sensation and pain analgesia.9 Oftentimes
individuals will also verbalize wanting to feel “something”,
even if it is pain.

Assessment

Professional community groups such as the American
Academy of Pediatrics and the American Medical Association
support early identification and screening for mental illness
within primary care settings.23, 24 Mental health checkups are
recommended annually during well visits and should include
an assessment of NSSI. Integral components of successful
mental health screening within primary care settings include
1) Brief and efficient screening for possible mental health
concerns (including NSSI), 2) Risk assessment of NSSI and
suicidal ideation, and 3) Referrals for follow-up mental health
services or immediate emergency medical or mental health
services if needed.25
General Considerations – When interviewing patients
who self-injure, it is important to maintain an attitude of
“respectful curiosity” that will minimize discomfort for them
and facilitate their disclosure of the extent and underlying
function of their self-injury.26 Providers should avoid labeling
the patient’s self-injury as “wrong” as this will likely serve to
close off further communication with the patient and decrease
their chances of seeking out treatment.18
Mental Health Screening – Mental health screening
measures that have been used within pediatric primary care
settings include the Pediatric Symptoms Checklist (PSC),
Pediatric Symptom Checklist-Youth Report (Y-PSC), and
Patient Health Questionnaire-9 for Adolescents (PHQ-9).
These measures can be obtained via the Columbia University
Northeast Florida Medicine Vol. 62, No. 3 2011 21

Teen Screen Program at www.teenscreen.org, www.brightfutures.org, and www.phqscreeners.com.
• PSC & Y-PSC - The PSC is a 35-item psychosocial
screen to detect cognitive, emotional, and behavioral
problems to facilitate referrals for appropriate intervention services. The PSC can be completed by parents
and the Y-PSC can be completed by adolescents ages
11 and up. Positive scores indicate the need for further
evaluation by a medical or mental health professional.
• PHQ-9 for Adolescents - The PHQ-9 is a self-report
depression screening that is completed by adolescents
11 to 18 years old. It consists of 9 questions with total
scores ranging from 0 to 27. Scores of 5, 10, 15, and
20 correspond to cutoff scores for mild, moderate,
moderately severe, and severe depression respectively.
Item 9 queries specifically for suicidal ideation and
self-harm.
NSSI Screening – Although these measures provide valuable tools for brief screening of psychiatric concerns, they do
not specifically assess for NSSI. To screen for the presence of
NSSI, the following questions are suggested:
• Have you deliberately harmed or injured yourself? How?
• Were you thinking of killing yourself?
A positive endorsement of NSSI will warrant a closer
assessment and risk assessment that will be discussed later.
NSSI and Risk Assessment – To date there are no official
guidelines in the assessment of NSSI within a primary care
setting. However, a recent article published in the Journal of
the American Board of Family Medicine offers an indispensable
guide in evaluating NSSI and conducting a risk assessment.18
This guide is modified and replicated in Table 1 (p.23) and
uses the mnemonic device “STOPS FIRE” that represents
each key assessment point. This tool is useful for provider to
remember key areas to assess in a patient presenting with NSSI.
Some of the domains assessed include suicidal ideation, type
of self-injury, function of NSSI, and intensity of urges. This
guide also establishes high-risk behavioral thresholds for each
area assessed that would necessitate a referral for immediate
follow-up behavioral health services.
Referral Recommendations – The level of risk of self-harm
largely determines the type of referral that will be necessary.
In general, patients who present as an imminent risk of suicide or who require immediate medical services due to the
extent of their NSSI (i.e. injury that requires sutures) will be
referred to emergency services (i.e. 911 or nearest emergency
room) and upon stabilization, an urgent appointment will
be made with a mental health provider. Patients who present
with moderate and low risk of self-harm should be referred
for outpatient behavioral health services that may include
counseling and medication management.

Treatment

Psychopharmacology – Treatment of NSSI is complicated
and ideally involves both psychopharmacology as well as
psychotherapeutic and behavioral interventions. Currently,
there is no U.S. Food and Drug Administration (FDA)
22 Vol. 62, No. 3 2011 Northeast Florida Medicine

approved psychopharmacological treatment for non-suicidal
self-injurious behavior. There are also few if any studies
evaluating the effectiveness of pharmacological options in
treating adolescents or children with NSSI. There are studies
in adults evaluating the use of medications from multiple
categories. These drugs are as follows:
• SSRIs. Given the frequent comorbidity of depression and
NSSI and the association of decreased serotonin levels
and impulsivity, the use of selective-serotonin reuptake
inhibiting antidepressant medications for treatment of
NSSI is theoretically sound. Studies have shown that
the use of selective-serotonin reuptake inhibitors such as
fluoxetine reduces the frequency of self-mutilation.27, 28
• Atypical Antipsychotics. In one case study, risperidone
was found to lead to remission of self-mutilation in
a patient with borderline personality disorder.29 A
placebo-controlled trial of treatment with aripiprazole
(Abilify™) of patients with borderline personality disorder did not show a reduction in self-injury.30
• Lithium. Lithium has been found to reduce deliberate
self-harm and to reduce deaths by suicide in patients
with mood disorders.31
• Anticonvulsants. There have been a few studies showing a reduction in self-mutilation with topiramate.32
Carbamazepine reduced behavioral dyscontrol (which
included cutting behaviors).33
• Opiate Antagonists. There have been multiple recent studies evaluating the effectiveness of the opiate antagonist
naltrexone. Theories have been developed that deliberate self-harm is an addictive-type of behavior involving
the endogenous opioid system. Studies have shown a
reduction and even cessation of deliberate self-harm
as well as a reduction in self-injurious thoughts when
patients are treated with naltrexone.34, 35
• Alpha Agonists. Clonidine reduced self-injurious urges
in patients with borderline personality disorder.36
• Glutamate-Modulating Agents. A case study has shown
evidence that glutamate-modulating agents such as
riluzole & N-acetylcysteine (NAC)decrease cutting
behaviors in patients with borderline personality
disorder.37
General Guidelines – General guidelines for the pharmacological treatment of NSSI in adolescents are somewhat
difficult to make due to the limitation in randomized,
controlled trials. Treatment of comorbid and underlying
psychiatric conditions such as depression and anxiety is very
important. Concerns about an increase in suicidal thinking
in adolescents using antidepressants and other psychotropic
medications should be thoroughly discussed with the patient
and his or her family. Close monitoring of patients started on
psychotropic medications is indicated. The protective effect
of antidepressant treatment has been shown to outweigh the
potential risk of increased suicidal ideation.38
Recommendations have suggested using SSRI antidepressants as the first-line treatment for self-harm with low-dose
www . DCMS online . org

Table 1 STOPS FIRE Assessment Guide 18
(Modified from the Original)

Area of Assessment

Potential Questions

( *Use of cutting as example)

High-Risk Indicators

Suicidal Ideation

“Do you ever thing about killing
yourself when you cut?”

Thoughts of suicide are
intense and occur before or after
episode of self-injury

Types

“In what ways do you self-injure?”

Multiple Types (≥ 3 Methods)

Onset/Duration

“When did you first begin to cut?”
“How long have you been cutting?

Early childhood onset;
Duration ≥ 6 months

Place/Location

“What parts of your body have
you cut?

Genitals, Breasts, or Face

Severity of Damage

“How deep do you cut?”
“Have you ever had to go to
hospital after you cut?”
“Have your cuts ever needed
stitches?”

Hospitalization or suturing
the required;
Reopening of wounds

Functions

“What do you get out of cutting?”
“How do you usually feel before
after you cut?”

Any relationship to suicide
(e.g., reduces suicidal
impulses)

Intensity of self-injury
urges

“How strongly would you rate
your urge to cut usually from
0 to 100?”

70 or higher

Repetition

“Roughly, how many times
have you cut since you started?”

11-50 (Moderate Risk);
≥ 50 (High Risk)

Episodic frequency

“How often do you cut in a typical day/week?"

atypical antipsychotic medications as a second-line intervention.39 Third-line treatment could involve lithium or an
anticonvulsant mood-stabilizer. In cases of self-mutilation
that do not respond to the aforementioned treatments,
naltrexone or clonidine may be added. Omega-3 fatty acids
have been shown to lower impulsive aggression in patients
with borderline personality disorder and may be an additional
pharmacologic intervention.40 Interestingly, there is evidence
that benzodiazepines, specifically alprazolam, can worsen
behavioral uncontrollability, thereby increasing self-injurious
behaviors.41

Psychological Treatments

There are a limited number of randomized clinical studies
examining the efficacy of different psychotherapies in the
treatment of self-injury. However, there are several evidencebased therapies that have been used for the treatment of selfinjury, including cognitive behavioral therapy and dialectical
behavior therapy.
www . DCMS online . org

Multiple times per week; ≥ 5 wounds per episode

Cognitive-Behavioral Therapy (CBT) – Cognitivebehavioral therapy has been widely discussed as a viable treatment option for the reduction of self-injury.16 Components
of this approach include the use of an assessment to evaluate
the function of self-injury, skills-training (problem-solving,
assertive communication), application of behavioral interventions (manipulating reinforcers, exposure, activity scheduling)
and cognitive restructuring. Studies using manual assistedcognitive behavioral therapy (MACT) have yielded reductions
in self-injury and increased periods of time between episodes
of self-injury. These changes have been observed over 12
months after treatment.42
Dialectical Behavior Therapy (DBT) – DBT is also a welldocumented treatment for suicidal and parasuicidal behavior
and incorporates similar techniques to CBT. It has proven
efficacy in the treatment of borderline personality disorder
and in the reduction of suicidal behavior. There has also been
a documented benefit in the reduction of NSSI.43 Research
Northeast Florida Medicine Vol. 62, No. 3 2011 23

is ongoing in determining whether DBT is superior to other
modes of therapy in the reduction of NSSI.
The goal of DBT when working with individuals with
self-injurious behaviors is to identify the antecedents and
consequences of NSSI to understand the function of the
behavior and identify pathways for change. Once the function of self-injury has been identified, there is an attempt to
identify alternative and incompatible behaviors. Learning
to accept negative affective states without trying to change
these feelings or circumstances is a focus of treatment. Main
components of DBT include 1) Decreasing life threatening
behaviors, 2) Decreasing therapy-interfering behaviors, 3)
Decreasing quality of life-interfering behaviors, and 4) Increasing behavioral skills.
The main skills taught include mindfulness, emotional
regulation, interpersonal effectiveness, distress tolerance, and
“walking the middle path skills”. Mindfulness skills emphasize
the importance of focusing on thoughts, actions, and experiences in the present without judgment and can help reduce
stress and easier to cope with daily problems. Distress tolerance strategies are used for coping with distressing emotions,
situations, and crises. They can be used to detract from urges
for self-harm and encourage use of incompatible behaviors.
Emotional regulation skills promote increased understanding
of emotions and the ability to manage them. Attention is
paid to increasing positive emotions and reducing negative
emotions. Relationship skills or interpersonal effectiveness
skills teaches patients to meet their goals in relationships
with other people. Lastly, “walking the middle path skills”
is used exclusively with adolescents and involves teaching
family–based skills that include validation, behavioral skills,
and specific problems between parents and teens. This form
of treatment is delivered in a combination of group and
individual therapy modalities.

Effective psychotherapeutic services along with pharmacological interventions are available for patients who self-injure.
Pharmacological treatment is likely to include consideration
of SSRI therapy if clinically indicated and potential referral to a psychiatrist. A behavioral health provider is able to
provide effective psychotherapies that may involve CBT or
DBT. The availability of DBT outpatient treatment is often
limited by the intensive nature of treatment and scarcity of
mental health providers trained in this treatment modality.

Ross S, Heath N. A study of the frequency of self-mutilation
in a community sample of adolescents. Journal of Youth and
Adolescence. 2002; 31:67-77.

7.

Rodham K, Hawton KE. Reasons for deliberate self-harm:
Comparisons of self-poisoners and self-cutters in a community
sample of adolescents. Journal of the American Academy of Child
and Adolescent Psychiatry. 2004; 43:80-87.

8.

Laye-Ghindu A, Schonert-Reichl KA. Non-suicidal self-harm
among community adolescents: Understanding the “whats”
and “whys” of self-harm. Journal of Youth and Adolescence.
2005; 34:447-457.

mental illnesses and substance use disorders constitute a profoundly
vulnerable segment of the homeless population. It is well documented
that untreated mental illness and chemical addictions can be both a
cause of homelessness and a life-shortening consequence of a life on the
streets. This paper will discuss the most common barriers to accessing
psychiatric and primary care for homeless persons and explore the devastating effects comorbid disorders (e.g., serious mental illness, substance
use disorders, and general medical conditions) can produce in persons
struggling to avoid or escape homelessness. It will conclude by proposing an integrated model of care to better meet the clinical needs of this
highly underserved population.

Introduction

Individuals with persistent mental illnesses and substance
use disorders constitute a large number of the homeless population in this country. Although methodological limitations
may constrain attempts to count precisely the number of
people who are homeless and also contending with mental
illness, addictions or both, several investigations provide reliable estimates. In the United States there are an estimated
643,000 persons who are homeless on any given night and
over one million citizens who experienced homelessness at
some point during the 2008 year.1 In Duval County there
are an estimated 3,500 individuals who are homeless at any
given time and well over 2,500 who are literally living on the
street due to lack of emergency shelter beds.2
The causes of homelessness are myriad and complex. Many
are socially systemic and range from high unemployment, a
low minimum wage standard, a dearth of low income housing options, and the lack of universal access to health care.
In addition, there are personal factors that can create a loss
of stable housing and shelter such as domestic violence, recent incarceration as well as extended medical or psychiatric
hospitalizations.3
Without doubt, the presence of untreated mental illness
and addictions can be both a cause and consequence of
homelessness. The most recent study conducted by the U.S.
Conference of Mayors, for instance, estimated that 26% of
the homeless population in this country suffers from a serious
mental illness such as schizophrenia, bipolar disorder, major
depression or posttraumatic stress disorder. 4 Other data
gathered from several studies over the years support a range
between 22 and 33%.5-6 Further, the Substance Abuse and
Address Correspondence to: Richard C. Christensen, MD, MA,
Professor and Chief, Division of Public Psychiatry, University
of Florida College of Medicine-Gainesville. Director of Behavioral Health Services, Sulzbacher Center, Jacksonville, Florida.
Email:rchris@ufl.edu.

26 Vol. 62, No. 3 2011 Northeast Florida Medicine

Mental Health Services Administration has estimated that
approximately 38% of the homeless population is dependent
upon alcohol and 26% actively abuse other drugs.7 In Duval
County, the 2009 point-in-time census showed that nearly
46% of the homeless population surveyed acknowledged their
lives had been impacted by the effects of mental illness and
nearly 58% reported a substance use disorder.2

Case Example

A typical example of a mentally ill homeless person needing treatment is Kevin, a 32-year-old male with a history of
schizophrenia, alcohol dependence and noninsulin dependent
diabetes. His family allowed him to live with them until 6
years ago when they decided they could no longer tolerate
his substance use and non-adherence to his psychiatric and
primary care treatment. Since that time, he has been living
on the street and occasionally in local shelters. On numerous
occasions he has been involuntarily committed to the local
crisis stabilization unit due to psychotic exacerbations and
bizarre public behavior. He has also been frequently arrested
for trespassing, disorderly conduct and alcohol-related charges.
During his periods of inpatient treatment and incarceration,
he is treated with psychotropic medication and is provided
primary care, but upon his release he has no established clinical
follow-up since he lacks public or private health insurance.
Although he is unable to work for any extended period of
time because of his persistent mental illness, he has not been
able to negotiate the disability application process due to his
cognitive disorganization, ongoing substance use issues and
lack of stable housing.

Obstacles to Treatment for Homeless Persons

Barriers to health care for homeless persons include a wide
list of potential obstacles.8 Although some are common to
the general population, those described here represent formidable obstacles for homeless persons who are mentally ill
and/or addicted. Indeed, accessing health care, particularly
behavioral health services (e.g., psychiatric care, counseling,
and addiction services) can be nearly an impossible task for
most homeless persons due to the following road blocks:
Lack of public or private insurance – The most recent
estimate of individuals in this country who lack some form
of health care insurance increased from 46.3 million in 2008
to 50.7 million in 2009.9 The Medicaid system is the most
important insurer for persons living in poverty with serious
mental illness and will likely grow under health reform.10
Not surprisingly, however, it has been estimated that nearly
70% of the homeless population lack any form of health
insurance, including Medicaid.11 Moreover, “coverage” does
not always translate into “access,” particularly with regard
www . DCMS online . org

to federal/state-supported Medicaid plans. Many private
psychiatrists and health care organizations, particularly in
Duval County, do not accept Medicaid patients due to the
low reimbursement schedule and what are perceived to be
onerous documentation requirements. Hence, even for those
homeless persons who may qualify to receive this form of
public insurance, their ability to locate and readily access a
provider is highly limited.
Lack of money – This barrier seems so obvious it requires
little explanation. However, a homeless person’s lack of
disposable income hinders seeing a private practitioner, the
purchasing of prescriptions (even generics) and medical supplies, procuring identification required at clinics, covering
the minimal co-pays required at many safety net medical/
dental organizations, or obtaining bus fare to access a “free”
clinic or emergency department. Those homeless persons who
lack insurance and the financial means to pay out-of-pocket
expenses are unable to access the vast majority of health care
systems or purchase the medications prescribed through
emergency services.
Lack of transportation – Most homeless persons do not
own personal vehicles and frequently cannot readily obtain
the money needed to pay for a cab or the city bus. Moreover,
navigating a complex public bus system, frequently requiring
multiple transfers, can be an overwhelming task for persons
who struggle with mental illness. Yet many have mobility
problems due to multiple medical illnesses and cannot easily
walk a mile or two to a safety net clinic, emergency department or public crisis unit. Because of their social marginalization, mentally ill homeless persons (particularly those with
co-occurring disorders), can no longer rely upon relatives or
friends who might assist them with a ride to a very limited
number of free clinics or safety net organizations. In other
words, services that might be “available” to homeless persons
are not always easily “accessible” due to barriers related to
securing and effectively utilizing transportation.
Lack of personal identification – Most health care organizations and clinics, even those that are designed to be
safety net options for homeless persons, require proof of
identification. Since the terrorist event of September 11,
2001, requirements for obtaining necessary documentation
to verify a homeless person’s identity have become increasingly complex and difficult.11 Oftentimes in order to obtain a
state-issued photo ID, a birth certificate and mailing address
are required, items a homeless person usually does not have.
In particular, the process of locating, tracking and obtaining
one’s birth certificate and the costs associated with the requests
are frequently beyond the abilities of homeless individuals
who struggle with mental illness, cognitive challenges or the
effects of ongoing substance use.
Inability to access entitlements – The process involved in
the application for Social Security benefits (SSI/SSDI), as well
as public health insurance, requires a diligent and oftentimes
painstaking process of proving disability. Criteria are strictly
defined under the guidelines provided by the Social Security
www . DCMS online . org

Administration (SSA). In all cases, what is minimally required
is a clear and coherent set of medical records documenting disability that have followed the patient over time. Moreover, an
applicant must tenaciously follow-up with required telephone
interviews as well as mandated physical/psychological examinations required by the SSA. In general, applications for these
benefits can go through several rounds of appeal and review,
extending the process to several years.12 For most homeless
persons who live chaotic, day-to-day lives, particularly those
who struggle with cognitive, mood or psychotic disorders,
the process is an administrative gauntlet that cannot be run
without the assistance of a dedicated advocate, outreach
worker or case manager. 13

Psychiatric Outreach and Engagement

Case Example continued – The psychiatric street outreach
team affiliated with the local homeless center has been contacted by a member of a local church. Kevin is reported to be
lying in the church doorway, partially clothed and smelling
of urine, claiming he is the “pastor and prophet for all who
come unto me.” Upon approach, Kevin is very guarded and
initially will not make eye contact or speak to the outreach
workers. However, he recognizes the team leader as someone
who has provided a shelter bed for him in the past. He agrees
to return to the shelter with the outreach team, but is only
willing to stay “for just a couple of days since I need to watch
over my church.” He admits he has been drinking for several
days and has not been taking any medications for his diabetes
or schizophrenia.
Working with homeless mentally ill persons, who may also
be suffering from the consequences of addiction as well as
untreated medical illness, requires a significant adaptation to
traditional medical practice.14 The very way in which most
mentally ill homeless persons enter into psychiatric treatment differs from the traditional process that might involve
a referral from a primary care provider, insurance company,
or an employer. It should be remembered that many homeless individuals are socially disaffiliated individuals who are
estranged not only from a web of familial or intimate relationships, but medical and behavioral health service systems as
well. Those with severe mental illness have often experienced
previous treatment in public-funded settings (e.g., crisis units,
jails, busy emergency departments, prisons) that are not always remembered as being welcoming or recovery-oriented
environments.15 Hence, the very first step to fostering care
is establishing rapport and relationship with persons who are
oftentimes highly suspicious of mental health providers. This
is most commonly accomplished through community-based
outreach initiatives that seek to foster relationship and trust
with the identified homeless person, whether they are living
on the street, in an abandoned house or in a shelter. 16
One example of this approach in Duval County can be
seen at the Sulzbacher Center, a large multidisciplinary service
center for homeless persons located in urban Jacksonville. Two
medical/psychiatric street outreach teams scour the downtown
and beaches areas on a daily basis looking for persons who are
unsheltered and in need of services. Each of the two Homeless
Northeast Florida Medicine Vol. 62, No. 3 2011 27

Outreach Project Expansion (HOPE)Teams consist of two
case managers as well as a primary care nurse practitioner and
psychiatrist. The initial approach is to meet the client where
he or she is, literally and figuratively, in order to establish
rapport and build a relationship. For most homeless persons
who suffer from mental illness, their initial personal goals
will likely consist of meeting basic human needs rather than
pursuing psychiatric or medical care.17
Before any discussion of treatment begins, the engagement
process must first address issues of shelter, food, clothing, and
safety. This will often involve entry into a safe living environment (e.g., Sulzbacher Center shelter) where survival needs
can be initially addressed. Once the engagement process has
reached the point of introducing mental health and/or primary
care services, which may take weeks or months, attempts
will be made to move the person to a greater level of insight
regarding his/her mental illness, addiction or both. Employing
techniques of harm reduction and motivational interviewing,
the shelter-based team, headed by the psychiatrist, will help
the person begin to identify the barriers that are preventing
him/her from reaching their life goals. As the individual
recognizes the need for treatment and change, he/she is then
offered a more intensive level of treatment involving active
participation in their personal recovery plan.

Homelessness and Co-Morbid Conditions

Case Example continued – Because Kevin had been
drinking heavily prior to entering the shelter, he agreed to
the medical team’s recommendation that he enter the local
detox unit where he was medically monitored and treated for
alcohol withdrawal. While there his oral hypoglycemic was
re-initiated. However, he refused all antipsychotic medications.
After four days he returned to the shelter where he was willing
to stay “for a few more days.” Over a two week period he met
several times, briefly, with the shelter-based psychiatrist and
discussed his goal of getting his own apartment and eventually
obtaining his driver’s license. During this time he was willing
to be seen in the shelter’s primary care clinic for his diabetes,
but was hesitant to start antipsychotic medication or begin
substance abuse treatment. Finally, after 6 weeks he agreed
to take a “low dose” of an antipsychotic medication and to
see the psychiatrist on a regular biweekly basis.
It is well established that even in the general population
persons with the most severe mental illnesses have the highest
rates of co-occurring substance related disorders.18 According
to a national epidemiological survey, for instance, substance use
disorders are co-morbid in approximately 20% of persons with
depression and 15 percent with anxiety disorders.19 Moreover,
people treated for schizophrenia and bipolar disorder are 12
and 20 times more likely to be treated for alcohol abuse,
and 35 to 42 times more likely to be dependent upon illicit
drugs, respectively. 20, 21 However, one recent study revealed
that greater than 50% of adults known to have co-morbid
mental illness and a substance use disorder did not receive
treatment for either condition during the previous year.22 The
obvious consequences of delayed or lapsed treatment includes
28 Vol. 62, No. 3 2011 Northeast Florida Medicine

more severe symptoms, frequent relapses, multiple crises
hospitalizations, and loss of employment and employability.
Not surprisingly, co-occurring disorders are directly related
to the loss of stable housing and, consequently, homelessness.
Once on the streets, the risk of prolonged, chronic homelessness increases due to the impact of the dual disorders. In
fact, one study of chronically homeless persons (i.e., those
individuals who had been on the streets for one year or longer
or at least 4 times in the past 3 years) found that the presence
of a co-occurring disorder was the expectation, rather than
exception, among this difficult-to-engage population.23 In
other words, those persons who suffer from a serious mental
illness like schizophrenia or bipolar disorder, as well as a
substance use disorder (SUD), are at greater risk of winding
up on the streets and experiencing great difficulty finding a
way out of homelessness.
Co-occurring disorders among homeless persons involve
more, however, than just mental illness and SUDs. Multiple
studies have shown that homelessness and mental illness
increase the risk of medical illness.24-26 It is well established
that even in the general population, persons with schizophrenia
or bipolar disorder have a life expectancy on average 25 years
less than those who do not have a serious mental illness. 27
However, the risk for premature death among the population
of homeless persons who suffer from mental illness is extreme.
A 10-year longitudinal study of mentally ill homeless persons
and premature death conducted in urban Australia found that
the average age at time of death was 51 years.28 Untreated
chronic medical conditions, particularly cardiovascular and
respiratory illnesses, were the leading causes of death in this
particularly vulnerable cohort. Not surprisingly, mentally ill
homeless persons seek medical care far less often than their
age and illness matched domiciled counterparts largely due
to the social and personal obstacles identified earlier.29

Active Treatment and Recovery

Case Example Continued – While at the shelter Kevin
participated in Life Skills training, a diabetes education
class, and was actively engaged in both his primary care and
psychiatric treatment. On many occasions he stated he could
trust his doctors and believed they were there to help him. He
no longer made references to being the pastor of a local church
and his self-care was greatly improved. He met with his case
manager on a regular basis who initiated the Social Security
disability process and helped identify housing options. She
explained the housing program that might accept him had a
“No Substance Use” policy.
Mentally ill persons who are homeless and fighting to
overcome the formidable obstacles they face because of their
multiple medical and addiction issues, need so much more than
any one health care provider can provide. Those individuals
who struggle with the challenges related to homelessness,
mental illness, addiction and poor physical health require a
clinical approach that is simultaneously multidisciplinary and
integrated. A best practices medical model designed to meet
the needs of this hard-to-engage population will invariably
www . DCMS online . org

involve mental health, addiction, primary care and case
management services that are co-located and integrated.30, 31
An example of this clinical approach and practice can be seen
at the Sulzbacher Center in Jacksonville.
The Sulzbacher Center provides emergency shelter, case
management services, and housing programs for over 350
men, women and children at any given time. In addition, the
Sulzbacher Center has developed an integrated model of medical care that employs the use of psychiatric/medical outreach
teams, medical case managers and co-located behavioral health
and primary care clinics in the attempt to meet the needs
of homeless persons who contend with the “tri-morbidity”
of mental illness, addictions and life-threatening medical
disorders. The goal is to create an integrated, psychiatricmedical “home” that is accessible, physician-directed, recoveryoriented, multidisciplinary and continuous for persons who
are both literally and systemically “homeless.”
During an average month, over 400 individuals are treated
in the behavioral health clinic for mental illness and substance
use disorders, and greater than 600 persons receive primary
care treatment. Most of these persons receive all their psychiatric, primary care, substance abuse and case management
services in this one medical “home,” provided by a consistent
cadre of coordinated providers with whom they have formed
a continuous, consistent therapeutic relationship. The use of
electronic medical records allow the multiple providers the
capacity to communicate and coordinate their treatment
recommendations.

Conclusion

Case Example result – Because a major goal for Kevin
was to obtain his own apartment, he agreed to enter into a
program that was specifically designed to meet the needs of
chronically homeless persons who struggled with mental illness
and chemical dependence. After 3 months in the program, he
moved into his own apartment and is actively participating
in his recovery program on an outpatient basis. He recently
received SSI and volunteers as a peer support person at a
local drop-in center for persons who have persistent mental
illnesses. He maintains close contact with his case manager at
the homeless center and sees his treating physicians in the clinic
on a regular basis. His family, once again, is a part of his life.
Most physicians in Duval County do not work exclusively
with homeless persons and do not have ready access to supports provided by an integrated model of care. However,
there will be many times, whether in the emergency department, on the inpatient service, in an outpatient clinic, or
while volunteering one’s medical services, that the patient
receiving care is identified as being homeless. As noted, the
clinical approach to persons who are homeless and mentally
ill requires adaptations and special considerations in order
to foster recovery and rehabilitation.32
Recalling the central issues of access, engagement, comorbidity and service planning, the following clinical strategies
are the best when providing care to persons who are homeless, mentally ill and struggling with substance use disorders:
www . DCMS online . org

1) Engage Patiently – Because so many homeless mentally
ill persons view the health care system with suspicion and apprehension, meaningful engagement is frequently complex and
protracted. Empathy and persuasion may be the most important
therapeutic elements of the initial engagement process that may
span weeks or months before the individual establishes trust.
2) Assess Needs Broadly – Paying attention to the basic
needs of safety, food, clothing and emergency shelter, in addition to the medical symptoms, is essential during the initial
evaluation and follow-up. Understandably, the homeless
person may place a much higher priority on food and shelter
than on mental health, addiction or primary care services.
3) Shape Interventions Pragmatically – Treatment interventions need to be shaped according to the realities of the person’s living situation. The chaotic conditions of a shelter or the
street will affect adherence to the most basic treatment interventions. Providing samples of medications (rather than written
prescriptions), simplifying dosing regimens to once-a-day, and
developing safe storage strategies for medications to prevent
theft and exposure are measures that will improve adherence.
4)Retain Arduously – Nonadherence to treatment
regimens, lost or stolen medications, failure to show for
appointments, sporadic follow through with other service
agencies, and an inability to remain consistently abstinent
from substances of abuse should be expected occurrences.
Setting limits and establishing consequences should be designed to retain the homeless person in treatment rather than
justifying termination.
5) Include Housing Always – Treating a homeless person
with multiple medical and psychiatric issues will be difficult
unless the person has stable shelter. Treatment plans for a
patient who is homeless will always be incomplete unless there
is also an actionable strategy to obtain emergency, transitional
or permanent housing.32

References

1.

The 2009 Homeless Assessment Report to Congress. Available
at http://www.hudhre.info/documents/5thHomelessAssessm
entReport.pdf . Accessed April 24, 2011.

National Coalition for the Homeless.Why are People Homeless?,
2010. National Coalition for the Homeless, 2201 P St.
NW, Washington, DC 20036. Available at http://www.
nationalhomeless.org. Accessed April 24, 2011.

4.

The United States Conference of Mayors. Hunger
and homelessness in America’s cities, a 25 city survey.
Washington, DC. Conference of Mayors, 2008 Dec.
Available at: http://usmayors.org/pressrelaeases/documents/
hungerhomelessnessreport_121208.pdf. Accessed April 21, 2011.

Dr. Ashley Booth Norse and her husband, Ronald, became
parents of a baby boy, Hudson, born August 1. Dr. Booth Norse
is the DCMS President-Elect. She will become the third woman
DCMS President at the December 1 DCMS Annual Meeting.
Congratulations to this new family.
www . DCMS online . org

debate in healthcare and public policy circles. Projects across the country
for handling the high cost of health care has lead to the formation of the
Patient-Centered Medical Home. Terms such as “healing landscapes”
and “medical neighborhoods” have been used to describe the concept
of the medical home. The Jacksonville Urban Disparities Institute is
a part of The Community Affairs Department Shands Jacksonville
that was established in 1989 to address the unmet medical needs of
the community surrounding Shands Hospital. To decrease disparities
in mental health care across ethnic and economic lines, the University
of Florida Departments of Community Health and Family Practice
have partnered with the Department of Psychiatry to treat mental and
behavioral disorders. This paper describes the first intervention of this
partnership: treatment of anxiety disorders.

Patient-Centered Medical Home

One approach to the problem of maintaining access to
care while keeping cost contained is the concept of the
Patient-Centered Medical Home (PCMH). The principles
and standards that define a “medical home” are based on the
core values of primary care (easy access to first-contact care,
comprehensive care, coordination of care, personal relationship over time).1 The medical home adopts a whole person
orientation with a treatment team led by a personal physician
who takes responsibility for coordinating care among providers
for the entire life of the patient. An emphasis of the medical
home is on enhanced access to care by integrating all elements of the healthcare system and community and Health
Information Technology to optimize both care coordination
and provider payment.2
There have been several medical home programs started
across the country. Rather than a “cookie cutter” approach,
each program was uniquely designed to address the specific
challenges of the state. For example, North Carolina targeted lowering emergency room use for Medicaid recipients
with asthma.3 Pennsylvania implemented a chronic disease
management model with the intent of reducing costs for
chronic care by improving control to avoid emergency room
visits and hospital admissions.4 States that have focused on
transitioning an integrated healthcare system to the PCMH
model found that change does not always come easy. The
National Demonstration Project — a comprehensive evaluation of the PCMH programs started in 2006 — concluded
that transforming primary care delivery required a significant
Address Correspondence to: Brian Celso, PhD., Assistant Professor,
Department of Psychiatry, University of Florida College of MedicineJacksonville, 580 W. 8th St., Tower 2, Suite 6005, Jacksonville, FL
32209. Email: Brian.Celso@jax.ufl.edu.
www . DCMS online . org

effort on the part of providers.5 There was also a strong need
for resources and support external to the practices to make
a PCMH succeed.
The Jacksonville Urban Disparity Institute (JUDI) is a
community-based health initiative that oversees ten clinics
operated by the University of Florida serving a predominantly
minority population in the urban core of Jacksonville. Disparities in access to care and health outcomes are epidemic in
the disadvantaged areas of the city served by the JUDI clinics. Multi-disciplinary teams staff the clinics, which include
physicians, nurse case managers, midlevel providers, clinical
pharmacist, social worker and clinical psychologist. On July
1, 2010, six of the JUDI clinics became the first Academic
Medical Center affiliated ambulatory practices in Florida to
receive National Committee on Quality Assurance recognition as a Patient-Centered Medical Home. Consistent with
the PCMH philosophy, JUDI provides self-management
and care-management support of disease conditions with
high prevalence and major causes of morbidity and mortality to urban core residents such as such as sickle cell disease,
diabetes, HIV/AIDS, diabetes, hypertension and behavioral
health conditions like anxiety and depression.

Anxiety Disorders and Treatment

Anxiety disorders are a group of psychiatric conditions
that involve excessive anxiety and worry. According to
data collected by the National Institute of Mental Health
(NIMH), approximately 40 million American adults ages
18 and older, or about 18.1% of people in this age group
have an anxiety disorder in a given year.6 The range of anxiety disorders described in the DSM-IV TR include: Panic
Disorder, Obsessive-Compulsive Disorder, Post-Traumatic
Stress Disorder, Phobias and Generalized Anxiety Disorder.
Symptoms include exaggerated worry, discomfort, and irritability that appear to have no cause or are more intense
than the situation warrants. Physical signs typically reported
are restlessness, trouble falling or staying asleep, headaches,
trembling, muscle tension, and sweating. 7 A person may be
diagnosed with more than one anxiety disorder. For example,
someone with posttraumatic stress who experiences panic attacks. These disorders also frequently co-occur with substance
abuse or depressive disorders.
Along with serotonin reuptake inhibitors, one of the primary
treatments for anxiety disorders is the use of benzodiazepines.8
The pharmacology of benzodiazepines play a large role in
their efficacy as an anxiolytic. Benzodiazepines work by
potentiating the neurotransmission mediated by GABA, the
main inhibitory neurotransmitter in the Central Nervous
Northeast Florida Medicine Vol. 62, No. 3 2011 31

System, making neurons more difficult to excite. The first
benzodiazepine, chlordiazepoxide (Librium) was launched in
the United Kingdom in 1960, followed by diazepam (Valium)
in 1963. Alprazolam was introduced in the early 1980s. A
Washington Post article reported that 85 million prescriptions
were filled for the top 20 benzodiazepines in 2008, an increase
of 10 million over 2004, according to IMS Health, a healthcare information company based in Norwalk, Connecticut.9
The same article notes that “worldwide revenue for Xanax™
alone rose to $350 million last year, up nearly 50 percent from
2003, according to pharmaceutical company Pfizer’s financial
reports.”9 The majority of prescriptions for anxiolytics are
written by primary care physicians while psychiatrists write
less than 20% of the prescriptions.10
Patients who present to their primary care physician with
physical complaints often also report symptoms of anxiety
such as feelings of apprehension, fear or excessive worry. The
source of this uneasiness is not always known or recognized,
which can add to the distress being felt and lead to poorer
treatment outcomes.11 Benzodiazepines for treatment of
anxiety disorders are generally meant for short term use.
Long term use often results in limited efficacy and increased
abuse potential. Antidepressants such as serotonin reuptake
inhibitors are preferred for long term management. Longer
term use of benzodiazepines is commonly associated with
altered use patterns (from night time to daytime use), excessive
sedation, cognitive impairment, increased risk of accidents and
adverse sleep effects. Benzodiazepines also have an additive
effect with alcohol and other CNS depressants, increasing
the risk of fatal overdose when prescribed to persons with a
co-occurring alcohol or sedative use disorder.12
The benzodiazepines were first believed to be absent of
dependence-inducing properties. Subsequent research has
shown that tolerance, withdrawal and dependence are all liabilities with benzodiazepine use. The euphoric effects and
abuse potentials of alprazolam, diazepam and lorazepam
were shown to be similar with diazepam rated the highest.13
When the benzodiazepines were discontinued, symptoms of
the original disorder often recurred in a pattern about equal
to that experienced before treatment. Withdrawal symptoms
during discontinuation for both short half-life and long halflife benzodiazepines suggest that patients experience similar
difficulties.14 Alprazolam withdrawal, however may be more
severe and may occur after shorter-term use than with other
benzodiazepines.14 Feelings of jitteriness, palpitations, clamminess, sweating, nausea and confusion have all been reported.
The recurrence of anxiety symptoms in intensity greater than
that experienced prior to drug treatment is termed rebound.15
A secondary form of rebound after benzodiazepine discontinuation is rebound insomnia when a person’s previous sleep
disturbance returns. Rebound usually develops within hours
to days of benzodiazepine discontinuation, depending on the
particular benzodiazepine. Although reported symptoms may
seem similar to withdrawal, rebound is distinguished from
withdrawal in that rebound is a relapse of the underlying
anxiety disorder for which the drug was originally taken.
32 Vol. 62, No. 3 2011 Northeast Florida Medicine

Rebound of panic attacks occurred in almost one third of
patients treated with alprazolam.16 For patients with panic
disorder taking short and intermediate acting benzodiazepines
that experienced rebound anxiety, clonazepam was found to
be a useful alternative to alprazolam.16 Interestingly, rebound
was not experienced by those individuals treated by placebo.

Purpose of JUDI

A major consideration in the development of JUDI was to
assure that not just medical needs were met but also the mental
and behavioral health of patients were adequately addressed.
A particular concern was those patients with long-term use
of a benzodiazepine at risk of physiologic and psychologic
dependence on the drug. Thus, a decision was made by the
JUDI PCMH treatment team to identify patients prescribed
the high-potency, short-acting agent alprazolam because of
its strong potential for dependence and abuse. The team
needed to be prepared for patients who may be reluctant to
discontinue the drug due to over-reliance on the agent and
expect varying degrees of drug-seeking behavior. Because
benzodiazepines often are used with other types of medications, including other drugs with abuse potential that can
interact synergistically, the team was reminded to be vigilant
about recognizing signs of withdrawal and rebound anxiety.
A protocol driven treatment approach for anxiety was
developed in close collaboration with Psychiatry and the
PCMH team. It was implemented with two main goals.
The first goal was to wean those patients currently prescribed
alprazolam. The second goal was to improve the quality of
anxiety care by insuring that the primary care providers were
using evidenced based guidelines in the management of patients. To address the risk of rebound anxiety and withdrawal
symptoms, the longer-acting benzodiazepine clonazepam and
the antidepressant sertraline were started. The expectation
was that once sertraline was at a therapeutic level the use of
clonazepam would be reevaluated and weaned. Only those
patients who failed treatment would be referred to psychiatry
in accordance with the PCMH philosophy of increasing the
appropriateness of specialty services referrals. The protocol
followed by the primary care physicians is shown in Figure
1. A query of the JUDI clinics registry identified over 3000
patients diagnosed with an anxiety disorder. A letter was sent
to the patients informing them that alprazolam was no longer
to be prescribed at the JUDI and an alternative treatment
would be offered.
The preliminary results at JUDI showed a reduction in the
utilization of alprazolam in the target population by 86%.
While most studies of PCMH have shown improved patient
and provider satisfaction, patients may initially become more
dissatisfied with the care they receive.17 It was anticipated
that a backlash of complaints would quickly be forthcoming.
Our experience found that initially patients were resistant to
change. Sixty-one patients chose to leave the PCMH rather
than change from alprazolam. (Figure 1, p.33) However, some
patients, including their family members, communicated
that they appreciated the education about alprazolam and its
www . DCMS online . org

Figure 1 Medical Home Anxiety Treatment Protocol
PSWQ Screening ≥ 65

Currently Prescribed
Benzodiazepine?

No

Yes
Prescribed
Alprazolam?

Monitor

No

Yes
Age 70 or greater?

Consider PRN use and start
Sertraline 50 mg daily and
titrate to effect. Reassess in 6
months to consider continued
need for benzodiazepine.

Consider 50 mg increase of Sertraline
to maximum dose of 200 mg. For age
70 or greater 150 mg maximum dose.
Or increase of Citalopram to
maximum dose of 60 mg at week 8.

Reassess in 6 months
to consider need for
Clonazepam.

Positive response?

No
Refer for
Psychiatry
Screening

Yes

Reassess in 6 months
to consider need for
Clonazepam.

www . DCMS
online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 33

potential adverse side effects and that we “cared enough about
them as a practice to initiate this program, free of charge.”
Providers commented on the benefits of having a close working relationship with psychiatry. Many have indicated that
the protocol provides an important decision support tool
when managing complex patients. Thus, the authors believe
building an infrastructure of effective communication and
trust seems instrumental to maintain motivation among
patients and staff alike.

An aspiration of the PCMH was to encourage innovative
methods toward a more integrated and coordinated delivery
of healthcare.18 The implementation of a PCMH has shown
to improve the value and efficiency of care through better
prevention and care of chronic illness.19 The successful transition to a PCMH requires staff to maintain their motivation
while effectively managing the stress from constant change.20
Reform to the healthcare system through a PCMH may lead
to additional benefits such as improvement in the way mental
health services are provided as they have often been treated
as separate and distinct from medical care.21
This project shows how the medical home can be used to
improve management of anxiety disorders in the primary care
setting. It also underscores the risk associated with starting
a high potency, short-acting benzodiazepine, including high
abuse and dependence potential along with resistance to discontinuation. The next collaboration that will be undertaken
at JUDI is to evaluate the extended release formulation of the
antipsychotic SEROQUEL used for sleep and determine if
there is an equally effective alternative medication with fewer
side effects to treat insomnia.

Mental Health in Duval County
Niketa Walawalkar, MD, MPH; Thomas Bryant III, MSW;
Jeffrey Goldhagen, MD, MPH and Robert Harmon, MD
Mental health is as important as physical health to the
overall well being of individuals and communities. Mental
and behavioral disorders are more common than we might
imagine. A 2001 report published by the World Health Organization (WHO) states that more than 25% of people are
affected by these conditions at some time during their lives,
and one in four families is likely to have at least one member with a behavioral or mental disorder. Further increases
in these disorders are expected due to the aging population
and worsening social and economic problems. This growing
burden will not only amount to huge medical costs and disabilities, but also cause economic loss. According to the Kaiser
Foundation, more than 33% of U.S. adults and about 29%
of adults in Florida reported poor mental health in 2007. A
U.S. Department of Health and Human Services 1999 report
states that 55,000 of 275,000 children in Duval County, under 18 years of age, are living with a behavioral disorder. Less
than 50% of these children with mental health problems in
Duval County receive treatment. Despite the demonstrated
need for mental and behavioral health services, Florida ranks
48th in per capita mental health spending.
In 2008, 4,756 youth with Serious Emotional Disturbance
(SED) in Duval County received mental health services.The
Duval County Health Department (DCHD) estimated that
approximately 50% of foster care children are at risk of or
diagnosed with SED.1 SED includes all diagnosable mental,
behavioral, or emotional disorders and is listed as one of thirteen disabilities outlined in the Individuals with Disabilities
Education Act. SED includes, but is not limited to, learning
difficulties, unhappiness or depressed mood, hyperactivity,
aggression or self-injurious behavior and suicidal tendencies.
According to the 2009 Youth Risk Behavioral Survey, more
than 27% of high school students in Duval County felt sad
or hopeless almost every day for two or more weeks, which
made them unable to perform daily activities. More than
14% of high school students seriously considered attempting
suicide and 10% attempted suicide one or more times during the 12 months before the survey. In 2009, there were 16
suicide deaths per 100,000 persons in Duval County. This
was almost two points higher than the 2009 death rate for
Florida and approximately six points higher than the Healthy
People 2020 target, 10.2. This was more than a 33% increase
in the 2007 suicidal death rate, 12.1.
In 2009, 752 of 7,229 hospital visits per 100,000 persons
in Duval County were due to mental health disorders.2 Males
comprised slightly more than half the visits. Duval County
had 5,724 emergency room (ER) visits, 53% were females.2
www . DCMS online . org

Most of the hospital visits were by individuals 45-54 years
old, while most ER visits were among the 25-35 year olds.
Whites in Duval County had more than double the ER and
hospital visits compared to blacks. Among the six health zones,
Health Zone 2 (Arlington) had the highest number of ER
and hospital visits for mental and behavioral disorders with
Health Zone 1 (Urban Core) being a close second.
Substance Abuse and Mental Health Services Administration (SAMHSA) lists twenty-one locations in Jacksonville
that provide mental health services, of which five centers
provide inpatient and outpatient services and ten centers
provide only outpatient care. The state and counties work
together to provide mental health services across northeast
Florida. The DCHD provides mental health services through
all DCHD clinics. Services include individual, couples and
family counseling, parent education, psychiatric evaluation
and medication management for adults, children (6 years and
older) and families. DCHD clinics refer patients diagnosed
with mental illness to River Region Clinical Services and Renaissance Behavioral Health System for further treatment. The
Duval County Public Schools has the Exceptional Education
& Student Services program for children with SED to enhance
the quality of instructional services, educational opportunities
and support for students, their families and schools.
Mental health care in Duval County is fragmented,
with limited access to care and inefficient communication.
Preventive care is inconsistent and lacks case management.
Given these challenges, it is important to integrate services
and develop an efficient and seamless system of care. The
Northeast Florida Childrenâ&#x20AC;&#x2122;s Community Mental Health
Coalition, with a SAMHSA grant, started a system of care
initiative for children with SED called Kids â&#x20AC;&#x2DC;N Care in January 2011. Initiative members work in collaboration with the
community, schools and families of children to develop and
implement effective mental health services and establish
a system of care to recognize and respond to SED among
children in northeast Florida.
Mental health impacts all aspects of our community. It
is important that health care professionals, teachers, health
educators, social workers and the community recognize and
support individuals with mental and behavioral disorders.
Together we can help all residents of northeast Florida live
mentally healthier lives.
Resources:
1. Duval County Health Department, 2008
2. Agency for Health Care Administration (ACHA), 2009
Northeast Florida Medicine Vol. 62, No. 3 2011 35

Annual LBA Physician
Client Update

Tuesday, October 11, 2011
6:00 p.m. – 8:00 p.m.

The River Club of Jacksonville

Admission - $49 per person; Complimentary for LBA Clients.
Updates on key issues being faced by healthcare professionals
and practices today, to include:

Internal Controls

How Protected is Your Practice from Employee Theft?

SPEAKERS

2nd

Richard Brock

Jim White

Delena Howard

Carrie Jones

Compliance Audits

What are Auditors Looking for?

Financial Planning and Wealth Management

“Very informative

Specific Strategies for Physicians

presentation tailored for

Year End Tax Planning

physicians. This is why LBA

Are You Covering Your Bases?

is the leader in accounting for

To register, please call LBA at 904.396.4015 or visit LBAnews.com

physicians in Jacksonville.
I look forward to the next
presentation.”

CERTIFIED PUBLIC ACCOUNTANTS

Michael Loper, M.D.

HEALTHCARE CONSULTING SERVICES
RETIREMENT PLAN SERVICES
BW ad:ad

4/19/11

WEALTH MANAGEMENT
4:16 PM Page 1

www.TheLBAGroup.com

Serving Northeast
Florida Since 1898
BUSINESS
PERSONAL
LIFE
HEALTH

CONTRACT BACK-UP PHYSICIAN
4 + HOURS/MONTH
Octapharma Plasma is hiring for a Contract Back-Up
Physician in our Jacksonville and Orange Park, FL Donor
Centers! This position requires just 4 hours per month and
is a perfect opportunity to earn additional income.
GENERAL DESCRIPTION - To provide independent
medical judgment and discretion for issues relating to donor
safety, health and suitability for plasmapheresis and/or immunization. Provide federal and international mandated training and
supervision of donor center medical staff to assure compliance
with applicable laws in medically related areas. We provide onthe-job training.

™

WHO IS OCTAPHARMA PLASMA? - Octapharma Plasma,
Inc. is dedicated to improving the health and lives of people
worldwide by providing quality plasma products to our customers.
OPI owns and operates plasma collection centers throughout the
United States critical to the development of life-saving patient
therapies utilized by thousands of patients all over the world.
APPLY TODAY! -Apply today by sending your resume/CV to

The mission of We Care Jacksonville is
to improve healthcare access by developing and coordinating
a community-wide network of medical volunteers and
donated healthcare services to care compassionately for
the uninsured and underserved.

904-253-2205
wecarejacksonville.org

Department of Health, Bureau of Vital Statistics
Physicians’ Online Tutorial for
Completing Cause of Death on the Florida Death Record

The Department of Health Bureau of Vital Statistics, in cooperation with the Florida Medical Association and the Florida
Association of Medical Examiners, has an online tutorial for physicians. This complimentary tutorial, which is worth one
CME credit, takes about one hour to complete and can be accessed at: http://floridavitalstatisticsonline.com.
The tutorial is constructed for physicians, providing an overview of the death registration process in Florida and how to
go about properly completing the medical information on the death record. It provides sample case histories; an explanation of the physician’s, the medical examiner’s, and the funeral director’s responsibilities in getting death records filed; how
mortality data is used and why the death record is so important to families.
=====

Electronic Death Registration System Launched in Florida

Vital Statistics has moved to electronic filing of Florida Death records. This means the record is filed online, via a secure
Internet site, using the Electronic Death Registration System (EDRS). The user has direct access to the state database for
entry of death record information. EDRS increases accuracy and timeliness while improving statistics for state and national
surveillance systems.
Funeral directors are online users and complete the demographic/personal information on the decedent. The EDRS
record is then sent electronically to the physician for certifying the medical information.
The certifying physician can be an online user and complete the medical certification electronically, using EDRS; OR can
be an offline user and complete the medical certification via Fax Attestation. The fax is system generated and looks much
like the medical portion of the paper death record.
Questions? 904-359-6900, ext. 9020 • Quality Assurance • Bureau of Vital Statistics
P.O. Box 210 • Jacksonville, Florida 32231-0042
www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 37

38 Vol. 62, No. 3 2011 Northeast Florida Medicine

www . DCMS online . org

AAMSE Elects Jay Millson to 2011-2012 Leadership Post
Jay W. Millson, MBA, Executive Vice President of the
Duval County Medical Society (DCMS) in Jacksonville,
FL, is the new President of the American Association of
Medical Society Executives (AAMSE). Millson was installed
at AAMSE’s 30th Annual Conference July 20-23, 2001 in
Boston, MA. He will continue as DCMS EVP during his
term as AAMSE President.

being kicked, shoved and drowned as we try and navigate
our way to solid ground.” Jay then encouraged his colleagues
“to work together” and said, “Doing the swim, working with
other swimmers and drafting off each other provides a huge
advantage…likewise, leveraging our collective and combined
resources in organized medicine will be the only way we can
survive and not drown in a sea of uncertainty.”

Ja y j o i n e d t h e
AAMSE Board of Directors in 2006 after chairing the New
Medical Executives
Institute in 2001 and
has served on multiple
committees during his
fifteen-year membership in the Association.
AAMSE’s mission is to
advance the profession
of medicine by enhancing and recognizing
the talent and work of
medical society execuJay W. Millson, MBA - DCMS EVP and
tives.
Its membership
AAMSE President
comprises more than
800 executives from around the nation and represents over
360 medical societies. AAMSE focuses on the highest priority
issues facing physicians, their patients, and their medical societies, and works to develop progressive, collaborative solutions.

As for the bike portion of a triathlon, it is the longest and
requires the athlete to “remain strong, steady and committed.”
Jay challenged AAMSE that after 66 years in existence, the
Association needs to stay its course, “ride out the long road
ahead” and “not reinventing the wheel but working through
the evolution medical societies encounter daily in order to
remain relevant.”

Robert W. Seligson, Executive Vice President, CEO of the
North Carolina Medical Society in Raleigh, NC and the one
who hired Jay when both were on staff at the Florida Medical
Association (FMA), introduced him at the Board Installation Lunch on July 23. A congratulatory video prepared by
the DCMS staff was shown and a special plaque from the
DCMS Board of Directors was presented. It read in part,
“Recognition by your fellow executives of your longstanding
leadership, passion and vision for our medical profession is
an honor. Your knowledge and hard work on behalf of all
levels of organized medicine have prepared you for this role
and we applaud AAMSE for allowing you this opportunity.
We look forward to participating in this journey with you.”
In his speech to those gathered at the installation lunch,
Jay compared how AAMSE assists its members to the way
an athlete prepares for a triathlon’s swim, bike and run. Jay
took each basic event and connected it to medical executives’
professional activities.
He explained “the swim” is difficult, rough, and “somewhat terrifying” as you get kicked, punched, and poked
while trying to keep from drowning. He related this to the
pandemonium of health reform and how “Often times I feel
like my medical society and the physicians we represent are
www . DCMS online . org

Finally, the run is “the most painful element of the triathlon
because you typically start to cramp up, get dehydrated and
feel like walking.” Jay had a mentor who advised him to smile
as he ran because it both psycs out the competition while
making you feel better. He thanked the mentors who have
influenced him in his professional career and personal life and
explained, “Mentors provide the road for us to run on during
the race.” He concluded, “I am grateful for this opportunity
to lead AAMSE…Your support of me and the Association
will be the only way to achieve success [in the current Health
Reform environment]…smiling along the way."
An Orange Park, Florida native, Jay was hired as the Executive Vice President/CEO of the Duval County Medical
Society (DCMS) in October 2004. He oversees, through
administrative agreement, the management of four contiguous
county medical societies in Northeast Florida (400+ physicians in Clay, Nassau, St. Johns, and Putnam) in addition to
coordinating all advocacy and administrative functions for
the 2,000 DCMS members. Jay has spent his 18-year professional career in medical society management working first
for the FMA in Tallahassee, FL (1993-1995) in the area of
medical economics and then the Jacksonville-based American
Association of Clinical Endocrinologists (1995-2004), seven
of those years as Deputy CEO.
A long-standing advocate for physicians and patients, Jay
serves on multiple local boards that help promote access to
healthcare and healthy living including: Mayor’s Council for
Fitness & Wellbeing, YMCA, Healthy Start Coalition, We
Care, Northeast Florida Medical-Legal Partnership and more.
Jay received both his undergraduate degree in healthcare
management and masters of business administration from
Appalachian State University, where he also lettered in
football as a place kicker from 1989-1992. He enjoys racing
in triathlons with Ironman Florida (2002) and Wisconsin
(2004) being his most significant accomplishments. However,
his favorite hobby is spending time with his wife Whitney
and three daughters: Abby (13), Grace (11) and Emma (8).
Northeast Florida Medicine Vol. 62, No. 3 2011 39

DCMS Membership Applications
These physicians’ applications for membership in the
Duval County Medical Society are now being processed.
Any information or opinions you may have concerning
the eligibility of the applicants listed here may be directed
to Ashley Booth Norse, MD, DCMS Membership
Committee Chair (904-244-4106 or Barbara Braddock,
Membership Director (904-355-6561 x107).

During the Florida Medical Association (FMA) 2011 Annual Meeting, July 28-30 at Disney's Contemporary Resort in Orlando, FL, Dr.
Miguel A. Machado (above, left) was inaugurated as FMA President. Dr. Machado, a member of the St. Johns County Medical Society, is
a neurosurgeon in private practice in St. Augustine, FL. Also elected at the meeting were DCMS members: (above, L to R) Dr. W. Alan
Harmon, as FMA Treasurer and AMA Delegate; Dr. Nathan Newman as AMA Delegate; and Dr. Daniel Kantor as AMA Alternate Delegate
to the Young Physicians' Section. Congratulations to these physicians from Northeast Florida!

You can easily search for a DCMS memberâ&#x20AC;&#x2122;s practice
information and get a map and directions to their office.
Check it out

www.db.dcmsonline.org/directory
or use your SmartPhone QR reader!

Stay Connected!
42 Vol. 62, No. 3 2011 Northeast Florida Medicine

ď °

www.dcmsonline.org
www . DCMS online . org

Photo of surgery in a combat hospital in Al Taqaddum, Iraq, 2006, showing CDR Mark Gould and the surgical team removing
IED fragments from a wounded Marine. Dr. Gould is an Orthopedic Surgeon and is currently Director of Surgical Services at
Naval Hospital, Jacksonville. Photo taken by LCDR Ken Meehan.

â&#x20AC;&#x153;Duval County Medical Society has long played a critical role in bringing
together leaders in medicine to focus on national and regional issues and the
collective challenges health care providers face daily in their efforts to provide
quality health care to patients throughout the region. As one of the Navy's largest
medical treatment facilities with clinics in five locations across two states, and
as a member of the Northeast Florida Quality Collaborative, we understand
the value of this type of collaboration and see first-hand the mutually beneficial
partnership between DCMS and its members."
(Commanding Officer Captain Lynn Welling, Naval Hospital, Jacksonville)

Read more about the link between the U.S. Navy and DCMS in
the DCMS History Book to be published in 2012.
Plan to purchase your copy!
www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 43

Special thanks to the DCMS physicians and other
healthcare professionals who volunteered their time
and expertise to perform JSMP Student Athletic
Screenings August 6 & August 13 at Nemours
Children's Clinic & Wolfson Children's Hospital.
A total of 1,058 students were screened and
700+ physicians, healthcare professionals and other
volunteers assisted with the screenings.
The Jacksonville Sports Medicine Program
(JSMP) is a volunteer based organization that is
dedicated to the improvement and maintenance
ofSpecial
the physical
mental
well-being
ofand
studentthanksand
to the
DCMS
physicians
other
athletes
in
northeast
Florida.
healthcare professionals who volunteered their time
and
expertise
perform
JSMP
Athletic
Why
not get to
involved
next
year inStudent
this worthwhile
Screenings
August
6
&
August
13
at
Nemours
project? Go to www.jsmp.us for more information.
Children's Clinic & Wolfson Children's Hospital.
A total of 1,058 students were screened and
700+ physicians, healthcare professionals and other
volunteers assisted with the screenings.
The Jacksonville Sports Medicine Program
(JSMP) is a volunteer based organization that is
dedicated to the improvement and maintenance
of the physical and mental well-being of studentathletes in northeast Florida.
Why not get involved next year in this worthwhile
project? Go to www.jsmp.us for more information.
(L to R) Rena Smith with
Nemours and Dr. Ronald
Mars

In a MEDICaL MaLPRaCTICE CLaIM:
Be ready for anything and everything.

Decades of experience, true financial stability, and a
tough-as-nails defense team make First Professionals
a well-rounded — and yes, affordable — choice when
it comes to protecting your medical reputation and
career. No other Florida medical malpractice provider
knows the industry quite like we do, nor do they defend
our doctors with as much tenacity. We’re committed
to protecting you and everything you’ve got, with
everything we’ve got.

You save lives.
We save livelihoods.®
A volunteer performs a
screening test on a student

A financial advisor dedicated to the medical industry can help you navigate
changes in your practice’s finances.
The business of medicine, much like your practice itself, is forever evolving. And with new
financial opportunities and ongoing concerns — like protecting against fraud, managing risk and
anticipating the impact of insurance and reimbursements on cash flow — you need the guidance
of an advisor who uniquely understands your industry. At SunTrust, advisors with our Private
Wealth Management Medical Specialty Group work solely with physicians and their practices
to deliver solutions designed for the medical community. To schedule an appointment with an
advisor, call 904.632.2854 or visit suntrust.com/medicine to learn more.

Treasury and Payment Solutions

Lending

Investments

Financial Planning

Deposit products and services are offered through SunTrust Bank, Member FDIC.

Your patients no longer have to drive downtown for specialist vein care. Our state-of-the-art facility is
conveniently located just off the Baymeadows road exit on 9A. We provide the following treatment options:
• Radiofrequency ablation
• Laser ablation
• Ultrasound-guided chemical ablation

• Foam sclerotherapy
• Liquid sclerotherapy
• Ambulatory phlebectomy

We are a participating provider for Medicare, Tricare and most Commercial payers.
Please visit www.stjohnsvein.com for more information or call (904) 402-VEIN (8346)
to learn more about the care we can provide for your patients.
James St. George, M.D. is
a vascular specialist and a
diplomat with the American
Board of Radiology with a
Certificate in Interventional
Radiology. He completed
his fellowship training at
Harvard Medical School’s
9191 RG Skinner Parkway

•

Suite 303

w w w. stjo h n sve in . com •

46 Vol. 62, No. 3 2011 Northeast Florida Medicine

Brigham and Women’s Hospital and served for
12 years as faculty at Harvard Medical School,
Dartmouth Medical School and Drexal School of
Medicine. He also held the position of Head of
Special Procedures at Hahnemann Hospital in
Philadelphia. Dr. St. George takes the time to know
each patient and creates customized treatment
programs to obtain the best possible results.
•

Jacksonville, FL 32256

(904) 402-VEIN (8346)
www . DCMS online . org

NeFLMed Journal 4c ad 1:Layout 1

8/1/11

5:44 PM

Page 1

Your compassionate
guide leads to quality time.
Your patients have a guide to walk with, listen to
and support them through all stages of advanced
illness, Community Hospice of Northeast Florida.
For more than 30 years, we’ve been here with
answers and advice that promote choices and
quality time.
Ask us how we can work with you to share
that quality time. Contact us today.
904.407.6500 • 866.253.6681 toll free • communityhospice.com
Community Focused • Community Supported
Serving Baker, Clay, Duval, Nassau and St. Johns counties since 1979